|
CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 0024515006
|
| 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 Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 0024515005
|
| 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 Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
CAMPHOR-PHENOL 10.8 %-4.7 % TOPICAL SOLUTION [12562]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0024515006
|
| 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 Non-Gatekeeper |
$0.07
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| 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 |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CANAGLIFLOZIN 100 MG TABLET [201798]
|
Facility
|
OP
|
$23.94
|
|
|
Service Code
|
NDC 5045814030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Adventist Health Commercial |
$4.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.97
|
| Rate for Payer: Blue Shield of California Commercial |
$14.60
|
| Rate for Payer: Blue Shield of California EPN |
$11.68
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.82
|
| Rate for Payer: Heritage Provider Network Senior |
$14.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.76
|
| Rate for Payer: Multiplan Commercial |
$17.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.58
|
| Rate for Payer: TriValley Medical Group Senior |
$9.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.35
|
| Rate for Payer: Vantage Medical Group Senior |
$20.35
|
|
|
CANAGLIFLOZIN 100 MG TABLET [201798]
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 5045814030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$17.95 |
| Rate for Payer: Adventist Health Commercial |
$4.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.42
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.21
|
| Rate for Payer: Heritage Provider Network Senior |
$16.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.99
|
| Rate for Payer: Multiplan Commercial |
$17.95
|
|
|
CANDESARTAN 32 MG TABLET [23232]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 0378323293
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
CANDESARTAN 32 MG TABLET [23232]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 3334211707
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
CANDESARTAN 32 MG TABLET [23232]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 0378323293
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
|
|
CANDESARTAN 32 MG TABLET [23232]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 3334211707
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
|
|
CANDESARTAN 8 MG TABLET [23230]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 0378322593
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
CANDESARTAN 8 MG TABLET [23230]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 0378322593
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
CANGRELOR 50 MG INTRAVENOUS SOLUTION [210327]
|
Facility
|
OP
|
$1,260.31
|
|
|
Service Code
|
HCPCS C9460
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.47 |
| Max. Negotiated Rate |
$945.23 |
| Rate for Payer: Adventist Health Commercial |
$252.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$778.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.27
|
| Rate for Payer: Blue Shield of California Commercial |
$19.47
|
| Rate for Payer: Blue Shield of California EPN |
$19.47
|
| Rate for Payer: Cash Price |
$567.14
|
| Rate for Payer: Cash Price |
$567.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$579.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$806.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$583.52
|
| Rate for Payer: Heritage Provider Network Senior |
$583.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$601.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$228.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$315.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27.18
|
| Rate for Payer: Multiplan Commercial |
$945.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$504.12
|
| Rate for Payer: TriValley Medical Group Senior |
$504.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$455.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$417.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Vantage Medical Group Senior |
$22.31
|
|
|
CANGRELOR 50 MG INTRAVENOUS SOLUTION [210327]
|
Facility
|
IP
|
$1,260.31
|
|
|
Service Code
|
HCPCS C9460
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.12 |
| Max. Negotiated Rate |
$945.23 |
| Rate for Payer: Adventist Health Commercial |
$252.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$811.64
|
| Rate for Payer: Cash Price |
$567.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$579.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$680.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$583.52
|
| Rate for Payer: Heritage Provider Network Senior |
$583.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$228.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$315.08
|
| Rate for Payer: Multiplan Commercial |
$945.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$455.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$417.29
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
IP
|
$21.36
|
|
|
Service Code
|
NDC 7012710010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$16.02 |
| Rate for Payer: Adventist Health Commercial |
$4.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.76
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.46
|
| Rate for Payer: Heritage Provider Network Senior |
$14.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$16.02
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
OP
|
$21.36
|
|
|
Service Code
|
NDC 7012710010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Adventist Health Commercial |
$4.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.68
|
| Rate for Payer: Blue Shield of California Commercial |
$13.03
|
| Rate for Payer: Blue Shield of California EPN |
$10.42
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.22
|
| Rate for Payer: Heritage Provider Network Senior |
$13.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.95
|
| Rate for Payer: Multiplan Commercial |
$16.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.54
|
| Rate for Payer: TriValley Medical Group Senior |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.16
|
| Rate for Payer: Vantage Medical Group Senior |
$18.16
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
OP
|
$21.36
|
|
|
Service Code
|
NDC 7012710001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Adventist Health Commercial |
$4.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.68
|
| Rate for Payer: Blue Shield of California Commercial |
$13.03
|
| Rate for Payer: Blue Shield of California EPN |
$10.42
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.22
|
| Rate for Payer: Heritage Provider Network Senior |
$13.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.95
|
| Rate for Payer: Multiplan Commercial |
$16.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.54
|
| Rate for Payer: TriValley Medical Group Senior |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.16
|
| Rate for Payer: Vantage Medical Group Senior |
$18.16
|
|
|
CANNABIDIOL 100 MG/ML ORAL SOLUTION [222792]
|
Facility
|
IP
|
$21.36
|
|
|
Service Code
|
NDC 7012710001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$16.02 |
| Rate for Payer: Adventist Health Commercial |
$4.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.76
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.46
|
| Rate for Payer: Heritage Provider Network Senior |
$14.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$16.02
|
|
|
CAPMATINIB 150 MG TABLET [228060]
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
NDC 0078070956
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$212.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$137.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$187.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.05
|
| Rate for Payer: Blue Shield of California Commercial |
$152.50
|
| Rate for Payer: Blue Shield of California EPN |
$122.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$162.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$212.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$212.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$212.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.75
|
| Rate for Payer: Heritage Provider Network Senior |
$154.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$119.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$175.00
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$125.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$125.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$212.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$212.50
|
| Rate for Payer: Vantage Medical Group Senior |
$212.50
|
|
|
CAPMATINIB 150 MG TABLET [228060]
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
NDC 0078070956
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$187.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$161.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$169.25
|
| Rate for Payer: Heritage Provider Network Senior |
$169.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
NDC 0078071656
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$187.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$161.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$169.25
|
| Rate for Payer: Heritage Provider Network Senior |
$169.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
|
|
CAPMATINIB 200 MG TABLET [228061]
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
NDC 0078071656
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$212.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$137.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$187.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.05
|
| Rate for Payer: Blue Shield of California Commercial |
$152.50
|
| Rate for Payer: Blue Shield of California EPN |
$122.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$162.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$212.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$212.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$212.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.75
|
| Rate for Payer: Heritage Provider Network Senior |
$154.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$119.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$175.00
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$100.00
|
| Rate for Payer: TriValley Medical Group Senior |
$100.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$125.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$125.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$212.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$212.50
|
| Rate for Payer: Vantage Medical Group Senior |
$212.50
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0536252525
|
| 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 Non-Gatekeeper |
$0.09
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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 |
$0.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CAPSAICIN 0.025 % TOPICAL CREAM [1350]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0536252525
|
| 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: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0536111825
|
| 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 Non-Gatekeeper |
$0.06
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| 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 |
$0.05
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CAPSAICIN 0.075 % TOPICAL CREAM [9399]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0536111825
|
| 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: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
