|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM [106176]
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Adventist Health Commercial |
$0.68
|
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.88
|
| Rate for Payer: Dignity Health Senior |
$2.27
|
| Rate for Payer: Dignity Health Senior |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Senior |
$1.07
|
| Rate for Payer: TriValley Medical Group Senior |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: Vantage Medical Group Senior |
$2.27
|
| Rate for Payer: Vantage Medical Group Senior |
$2.88
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.71
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.64
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$2.58
|
| Rate for Payer: Dignity Health Senior |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$1.13
|
|
|
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]
|
Facility
|
OP
|
$64.43
|
|
|
Service Code
|
NDC 42858-750-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$54.77 |
| Rate for Payer: Adventist Health Commercial |
$12.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.32
|
| Rate for Payer: Blue Shield of California Commercial |
$39.30
|
| Rate for Payer: Blue Shield of California EPN |
$31.44
|
| Rate for Payer: Cash Price |
$35.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.77
|
| Rate for Payer: Dignity Health Senior |
$54.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.88
|
| Rate for Payer: Heritage Provider Network Senior |
$39.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$30.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$45.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.10
|
| Rate for Payer: Multiplan Commercial |
$48.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.77
|
| Rate for Payer: TriValley Medical Group Senior |
$25.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.77
|
| Rate for Payer: Vantage Medical Group Senior |
$54.77
|
|
|
BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH [107660]
|
Facility
|
IP
|
$64.43
|
|
|
Service Code
|
NDC 42858-750-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$48.32 |
| Rate for Payer: Adventist Health Commercial |
$12.89
|
| Rate for Payer: Cash Price |
$35.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.62
|
| Rate for Payer: Heritage Provider Network Senior |
$43.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.11
|
| Rate for Payer: Multiplan Commercial |
$48.32
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
IP
|
$4.08
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
HCPCS J0574
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$13.34 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.34
|
| Rate for Payer: Blue Shield of California Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California EPN |
$5.25
|
| Rate for Payer: Blue Shield of California EPN |
$5.25
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.06
|
| Rate for Payer: Dignity Health Senior |
$3.47
|
| Rate for Payer: Dignity Health Senior |
$4.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$1.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$3.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.47
|
| Rate for Payer: Vantage Medical Group Senior |
$4.06
|
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]
|
Facility
|
IP
|
$16.34
|
|
|
Service Code
|
HCPCS J0592
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$12.26 |
| Rate for Payer: Adventist Health Commercial |
$3.27
|
| Rate for Payer: Cash Price |
$8.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.57
|
| Rate for Payer: Heritage Provider Network Senior |
$7.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Multiplan Commercial |
$12.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.41
|
|
|
BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION [117588]
|
Facility
|
OP
|
$16.34
|
|
|
Service Code
|
HCPCS J0592
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$13.89 |
| Rate for Payer: Adventist Health Commercial |
$3.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.76
|
| Rate for Payer: Blue Shield of California Commercial |
$4.63
|
| Rate for Payer: Blue Shield of California EPN |
$4.63
|
| Rate for Payer: Cash Price |
$8.99
|
| Rate for Payer: Cash Price |
$8.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.89
|
| Rate for Payer: Dignity Health Senior |
$13.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.57
|
| Rate for Payer: Heritage Provider Network Senior |
$7.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.44
|
| Rate for Payer: Multiplan Commercial |
$12.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.54
|
| Rate for Payer: TriValley Medical Group Senior |
$6.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.89
|
| Rate for Payer: Vantage Medical Group Senior |
$13.89
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [34711]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
|
|
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$0.82
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET [34712]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
901700054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0904-7530-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 60505-0157-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| 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: Multiplan Commercial |
$0.65
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 60505-0157-1
|
| 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
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0904-7530-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 23155-192-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 23155-192-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 68001-309-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 68001-309-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
|
BUPROPION HCL 100 MG TABLET [9321]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 50268-143-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.80
|
| Rate for Payer: Dignity Health Senior |
$1.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.80
|
| Rate for Payer: Vantage Medical Group Senior |
$1.80
|
|
