|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
IP
|
$9.94
|
|
|
Service Code
|
NDC 61748-302-11
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$7.46 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.83
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.73
|
| Rate for Payer: Heritage Provider Network Senior |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
IP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Adventist Health Commercial |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.56
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.39
|
| Rate for Payer: Heritage Provider Network Senior |
$11.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 0378-6612-93
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California EPN |
$4.19
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Senior |
$6.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Senior |
$4.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
OP
|
$9.94
|
|
|
Service Code
|
NDC 61748-302-11
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.46
|
| Rate for Payer: Blue Shield of California Commercial |
$6.17
|
| Rate for Payer: Blue Shield of California EPN |
$5.83
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.45
|
| Rate for Payer: Dignity Health Senior |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.15
|
| Rate for Payer: Heritage Provider Network Senior |
$6.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Senior |
$3.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.45
|
| Rate for Payer: Vantage Medical Group Senior |
$8.45
|
|
|
ISOTRETINOIN 20 MG CAPSULE [10360]
|
Facility
|
OP
|
$16.83
|
|
|
Service Code
|
NDC 0555-1055-56
|
| Hospital Charge Code |
1710827
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$14.31 |
| Rate for Payer: Adventist Health Commercial |
$3.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.62
|
| Rate for Payer: Blue Shield of California Commercial |
$10.45
|
| Rate for Payer: Blue Shield of California EPN |
$9.88
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.31
|
| Rate for Payer: Dignity Health Senior |
$14.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.42
|
| Rate for Payer: Heritage Provider Network Senior |
$10.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$12.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Senior |
$6.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.31
|
| Rate for Payer: Vantage Medical Group Senior |
$14.31
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
IP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.22 |
| Rate for Payer: Adventist Health Commercial |
$1.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.70
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.62
|
| Rate for Payer: Heritage Provider Network Senior |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$6.22
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
OP
|
$11.84
|
|
|
Service Code
|
NDC 61748-304-13
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$10.06 |
| Rate for Payer: Adventist Health Commercial |
$2.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.88
|
| Rate for Payer: Blue Shield of California Commercial |
$7.35
|
| Rate for Payer: Blue Shield of California EPN |
$6.95
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.06
|
| Rate for Payer: Dignity Health Senior |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.33
|
| Rate for Payer: Heritage Provider Network Senior |
$7.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.96
|
| Rate for Payer: Multiplan Commercial |
$8.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.74
|
| Rate for Payer: TriValley Medical Group Senior |
$4.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.06
|
| Rate for Payer: Vantage Medical Group Senior |
$10.06
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
OP
|
$8.30
|
|
|
Service Code
|
NDC 0378-6614-93
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Adventist Health Commercial |
$1.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.22
|
| Rate for Payer: Blue Shield of California Commercial |
$5.15
|
| Rate for Payer: Blue Shield of California EPN |
$4.87
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.06
|
| Rate for Payer: Dignity Health Senior |
$7.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.14
|
| Rate for Payer: Heritage Provider Network Senior |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$6.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.32
|
| Rate for Payer: TriValley Medical Group Senior |
$3.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.06
|
| Rate for Payer: Vantage Medical Group Senior |
$7.06
|
|
|
ISOTRETINOIN 40 MG CAPSULE [10361]
|
Facility
|
IP
|
$11.84
|
|
|
Service Code
|
NDC 61748-304-13
|
| Hospital Charge Code |
1710009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Adventist Health Commercial |
$2.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.13
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.02
|
| Rate for Payer: Heritage Provider Network Senior |
$8.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.96
|
| Rate for Payer: Multiplan Commercial |
$8.88
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
1711608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.47
|
| Rate for Payer: Dignity Health Senior |
$1.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Senior |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Senior |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1.47
|
|
|
ISRADIPINE 2.5 MG CAPSULE [10362]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
NDC 16252-539-01
|
| Hospital Charge Code |
1711608
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.30
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
1715228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
ISRADIPINE ORAL SUSPENSION COMPOUND 1 MG/ML [4080283]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 9994-0802-83
|
| Hospital Charge Code |
1715228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$33.78
|
|
|
Service Code
|
NDC 50458-290-01
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$25.34 |
| Rate for Payer: Adventist Health Commercial |
$6.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.21
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.87
|
| Rate for Payer: Heritage Provider Network Senior |
$22.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$25.34
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 65162-630-03
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 49884-239-11
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 65162-630-03
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 67877-454-30
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$8.93
|
|
|
Service Code
|
NDC 10147-1700-7
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Adventist Health Commercial |
$1.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.13
|
| Rate for Payer: Cash Price |
$4.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.05
|
| Rate for Payer: Heritage Provider Network Senior |
$6.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$6.70
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$15.10
|
|
|
Service Code
|
NDC 0378-5100-93
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.32
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$8.86
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.84
|
| Rate for Payer: Dignity Health Senior |
$12.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.35
|
| Rate for Payer: Heritage Provider Network Senior |
$9.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$11.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.04
|
| Rate for Payer: TriValley Medical Group Senior |
$6.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.84
|
| Rate for Payer: Vantage Medical Group Senior |
$12.84
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 49884-239-11
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$15.10
|
|
|
Service Code
|
NDC 0378-5100-93
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$11.32 |
| Rate for Payer: Adventist Health Commercial |
$3.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.37
|
| Rate for Payer: Cash Price |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.22
|
| Rate for Payer: Heritage Provider Network Senior |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.78
|
| Rate for Payer: Multiplan Commercial |
$11.32
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 67877-454-30
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$33.78
|
|
|
Service Code
|
NDC 50458-290-01
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.11 |
| Max. Negotiated Rate |
$28.71 |
| Rate for Payer: Adventist Health Commercial |
$6.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.34
|
| Rate for Payer: Blue Shield of California Commercial |
$20.98
|
| Rate for Payer: Blue Shield of California EPN |
$19.83
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.71
|
| Rate for Payer: Dignity Health Senior |
$28.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.91
|
| Rate for Payer: Heritage Provider Network Senior |
$20.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.44
|
| Rate for Payer: Multiplan Commercial |
$25.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.51
|
| Rate for Payer: TriValley Medical Group Senior |
$13.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.71
|
| Rate for Payer: Vantage Medical Group Senior |
$28.71
|
|
|
ITRACONAZOLE 100 MG CAPSULE [10364]
|
Facility
|
OP
|
$8.93
|
|
|
Service Code
|
NDC 10147-1700-7
|
| Hospital Charge Code |
1712171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.59 |
| Rate for Payer: Adventist Health Commercial |
$1.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.70
|
| Rate for Payer: Blue Shield of California Commercial |
$5.55
|
| Rate for Payer: Blue Shield of California EPN |
$5.24
|
| Rate for Payer: Cash Price |
$4.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.59
|
| Rate for Payer: Dignity Health Senior |
$7.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.53
|
| Rate for Payer: Heritage Provider Network Senior |
$5.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$6.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.57
|
| Rate for Payer: TriValley Medical Group Senior |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7.59
|
|
