|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6068755801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 6068755811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 6068755811
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 6909784607
|
| 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 Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 6808475325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 4354739910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 6808475395
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 6909784507
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 6808475325
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 6909784507
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 2930041301
|
| 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 Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 5026819011
|
| 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 Non-Gatekeeper |
$0.51
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| 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 |
$0.37
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 4354739910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 2930041301
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| 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 |
$0.02
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 6808475395
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET [35184]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 5026819011
|
| 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: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Cash Price |
$0.37
|
| 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 Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
CYCLOPENT 1 %-TROPICAMIDE 1 %-PHENYLEPHRINE 2.5 %-KETOROLAC EYE DROPS [229170]
|
Facility
|
IP
|
$10.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$7.93 |
| Rate for Payer: Adventist Health Commercial |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.90
|
| Rate for Payer: Heritage Provider Network Senior |
$4.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$7.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.50
|
|
|
CYCLOPENT 1 %-TROPICAMIDE 1 %-PHENYLEPHRINE 2.5 %-KETOROLAC EYE DROPS [229170]
|
Facility
|
OP
|
$10.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Adventist Health Commercial |
$2.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.93
|
| Rate for Payer: Blue Shield of California Commercial |
$6.45
|
| Rate for Payer: Blue Shield of California EPN |
$5.16
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.90
|
| Rate for Payer: Heritage Provider Network Senior |
$4.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.41
|
| Rate for Payer: Multiplan Commercial |
$7.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.23
|
| Rate for Payer: TriValley Medical Group Senior |
$4.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.99
|
| Rate for Payer: Vantage Medical Group Senior |
$8.99
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$7.17
|
|
|
Service Code
|
NDC 6131439601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.62
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.85
|
| Rate for Payer: Heritage Provider Network Senior |
$4.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
NDC 0065039605
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$11.47 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.85
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.35
|
| Rate for Payer: Heritage Provider Network Senior |
$10.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: Multiplan Commercial |
$11.47
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$15.29
|
|
|
Service Code
|
NDC 0065039605
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Adventist Health Commercial |
$3.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.65
|
| Rate for Payer: Blue Shield of California Commercial |
$9.33
|
| Rate for Payer: Blue Shield of California EPN |
$7.46
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.46
|
| Rate for Payer: Heritage Provider Network Senior |
$9.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.70
|
| Rate for Payer: Multiplan Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.12
|
| Rate for Payer: TriValley Medical Group Senior |
$6.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Vantage Medical Group Senior |
$13.00
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$7.17
|
|
|
Service Code
|
NDC 6131439601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.59
|
| Rate for Payer: Blue Shield of California Commercial |
$4.37
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.44
|
| Rate for Payer: Heritage Provider Network Senior |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.02
|
| Rate for Payer: Multiplan Commercial |
$5.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.87
|
| Rate for Payer: TriValley Medical Group Senior |
$2.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.09
|
| Rate for Payer: Vantage Medical Group Senior |
$6.09
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 6131439603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 6131439603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.44
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 6131439603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.90
|
|
