|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 43547-338-10
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 0185-0048-01
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-118-01
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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 Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
IP
|
$0.95
|
|
|
Service Code
|
NDC 50268-112-15
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 65862-118-01
|
| Hospital Charge Code |
1711522
|
|
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 |
$0.07
|
| 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 Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 0185-0048-01
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| 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 Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 65162-754-10
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
BENAZEPRIL 40 MG TABLET [9222]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 43547-338-10
|
| Hospital Charge Code |
1711522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 65162-751-10
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-15
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-11
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 65162-751-10
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 43547-335-10
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-11
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 43547-335-10
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
BENAZEPRIL 5 MG TABLET [9223]
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-15
|
| Hospital Charge Code |
1711519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 65162-751-10
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
IP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-15
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 43547-335-10
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 65162-751-10
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
OP
|
$0.75
|
|
|
Service Code
|
NDC 50268-109-15
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.64
|
| Rate for Payer: Dignity Health Senior |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Vantage Medical Group Senior |
$0.64
|
|
|
BENAZEPRIL CRUSHED TABLET SUSPENSION [4089223]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 43547-335-10
|
| Hospital Charge Code |
ERX4089223
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION [212360]
|
Facility
OP
|
$742.14
|
|
|
Service Code
|
NDC 63459-348-04
|
| Hospital Charge Code |
NDG212360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.33 |
| Max. Negotiated Rate |
$630.82 |
| Rate for Payer: Adventist Health Commercial |
$148.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$396.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$509.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$630.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$408.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$556.60
|
| Rate for Payer: Blue Shield of California Commercial |
$460.87
|
| Rate for Payer: Blue Shield of California EPN |
$435.64
|
| Rate for Payer: Cash Price |
$333.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$341.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$630.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$630.82
|
| Rate for Payer: Dignity Health Senior |
$630.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$474.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$343.61
|
| Rate for Payer: Heritage Provider Network Senior |
$343.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$357.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.54
|
| Rate for Payer: Multiplan Commercial |
$556.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$270.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$247.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$630.82
|
| Rate for Payer: Vantage Medical Group Senior |
$630.82
|
|
|
BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION [212360]
|
Facility
IP
|
$742.14
|
|
|
Service Code
|
NDC 63459-348-04
|
| Hospital Charge Code |
NDG212360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.33 |
| Max. Negotiated Rate |
$556.60 |
| Rate for Payer: Adventist Health Commercial |
$148.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$509.85
|
| Rate for Payer: Cash Price |
$333.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$341.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$400.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$502.43
|
| Rate for Payer: Heritage Provider Network Senior |
$502.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$134.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$185.54
|
| Rate for Payer: Multiplan Commercial |
$556.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$270.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$247.95
|
|
|
BENZNIDAZOLE 100 MG TABLET [220221]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 0642-7464-10
|
| Hospital Charge Code |
ERX220221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
