|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$19.82 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.89
|
| Rate for Payer: Heritage Provider Network Senior |
$17.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.61
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
IP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$19.82 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.89
|
| Rate for Payer: Heritage Provider Network Senior |
$17.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.61
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Blue Shield of California Commercial |
$16.12
|
| Rate for Payer: Blue Shield of California EPN |
$12.89
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Senior |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.35
|
| Rate for Payer: Heritage Provider Network Senior |
$16.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.49
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Senior |
$10.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY [111311]
|
Facility
|
OP
|
$26.42
|
|
|
Service Code
|
NDC 0574-7045-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$22.46 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.82
|
| Rate for Payer: Blue Shield of California Commercial |
$16.12
|
| Rate for Payer: Blue Shield of California EPN |
$12.89
|
| Rate for Payer: Cash Price |
$14.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.46
|
| Rate for Payer: Dignity Health Senior |
$22.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.35
|
| Rate for Payer: Heritage Provider Network Senior |
$16.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.49
|
| Rate for Payer: Multiplan Commercial |
$19.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.57
|
| Rate for Payer: TriValley Medical Group Senior |
$10.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.46
|
| Rate for Payer: Vantage Medical Group Senior |
$22.46
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.08
|
| Rate for Payer: Blue Shield of California Commercial |
$19.59
|
| Rate for Payer: Blue Shield of California EPN |
$15.67
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.29
|
| Rate for Payer: Dignity Health Senior |
$27.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.88
|
| Rate for Payer: Heritage Provider Network Senior |
$19.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.48
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.84
|
| Rate for Payer: TriValley Medical Group Senior |
$12.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.29
|
| Rate for Payer: Vantage Medical Group Senior |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
OP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.08
|
| Rate for Payer: Blue Shield of California Commercial |
$19.59
|
| Rate for Payer: Blue Shield of California EPN |
$15.67
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.29
|
| Rate for Payer: Dignity Health Senior |
$27.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.88
|
| Rate for Payer: Heritage Provider Network Senior |
$19.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.48
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.84
|
| Rate for Payer: TriValley Medical Group Senior |
$12.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.29
|
| Rate for Payer: Vantage Medical Group Senior |
$27.29
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$24.08 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.74
|
| Rate for Payer: Heritage Provider Network Senior |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY [24731]
|
Facility
|
IP
|
$32.11
|
|
|
Service Code
|
NDC 0574-7040-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$24.08 |
| Rate for Payer: Adventist Health Commercial |
$6.42
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.74
|
| Rate for Payer: Heritage Provider Network Senior |
$21.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.03
|
| Rate for Payer: Multiplan Commercial |
$24.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65162-752-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-116-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-116-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 43547-336-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 43547-336-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65162-752-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
BENAZEPRIL 10 MG TABLET [9220]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 50268-110-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 43547-337-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-117-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 65162-753-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65162-753-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 43547-337-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 50268-111-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
BENAZEPRIL 20 MG TABLET [9221]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 50268-111-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
