|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 54838-511-80
|
| 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: 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 |
$0.05
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 54838-511-80
|
| 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 Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$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 Permanente of CA Commercial |
$0.03
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 42192-339-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
|
IP
|
$79.20
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.34 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Adventist Health Commercial |
$15.84
|
| Rate for Payer: Adventist Health Commercial |
$25.92
|
| Rate for Payer: Cash Price |
$43.56
|
| Rate for Payer: Cash Price |
$71.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$60.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$97.20
|
| Rate for Payer: Multiplan Commercial |
$59.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.22
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
|
OP
|
$129.60
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$139.86 |
| Rate for Payer: Adventist Health Commercial |
$25.92
|
| Rate for Payer: Adventist Health Commercial |
$15.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$69.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$67.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$71.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$97.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.86
|
| Rate for Payer: Blue Shield of California Commercial |
$55.08
|
| Rate for Payer: Blue Shield of California Commercial |
$55.08
|
| Rate for Payer: Blue Shield of California EPN |
$55.08
|
| Rate for Payer: Blue Shield of California EPN |
$55.08
|
| Rate for Payer: Cash Price |
$71.28
|
| Rate for Payer: Cash Price |
$71.28
|
| Rate for Payer: Cash Price |
$43.56
|
| Rate for Payer: Cash Price |
$43.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$110.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.32
|
| Rate for Payer: Dignity Health Senior |
$110.16
|
| Rate for Payer: Dignity Health Senior |
$67.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.00
|
| Rate for Payer: Heritage Provider Network Senior |
$60.00
|
| Rate for Payer: Heritage Provider Network Senior |
$36.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$61.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$90.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$90.72
|
| Rate for Payer: Multiplan Commercial |
$97.20
|
| Rate for Payer: Multiplan Commercial |
$59.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Senior |
$51.84
|
| Rate for Payer: TriValley Medical Group Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$110.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.32
|
| Rate for Payer: Vantage Medical Group Senior |
$110.16
|
| Rate for Payer: Vantage Medical Group Senior |
$67.32
|
|
|
HYPROMELLOSE 2 % INTRAOCULAR SYRINGE [29834]
|
Facility
|
OP
|
$75.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Adventist Health Commercial |
$15.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.70
|
| Rate for Payer: Blue Shield of California Commercial |
$46.12
|
| Rate for Payer: Blue Shield of California EPN |
$36.89
|
| Rate for Payer: Cash Price |
$41.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.26
|
| Rate for Payer: Dignity Health Senior |
$64.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.00
|
| Rate for Payer: Heritage Provider Network Senior |
$35.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$36.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.92
|
| Rate for Payer: Multiplan Commercial |
$56.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$30.24
|
| Rate for Payer: TriValley Medical Group Senior |
$30.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.26
|
| Rate for Payer: Vantage Medical Group Senior |
$64.26
|
|
|
HYPROMELLOSE 2 % INTRAOCULAR SYRINGE [29834]
|
Facility
|
IP
|
$75.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Adventist Health Commercial |
$15.12
|
| Rate for Payer: Cash Price |
$41.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.00
|
| Rate for Payer: Heritage Provider Network Senior |
$35.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.90
|
| Rate for Payer: Multiplan Commercial |
$56.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.03
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.30
|
| Rate for Payer: Heritage Provider Network Senior |
$46.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.11
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$207.20 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$207.20
|
| Rate for Payer: Blue Shield of California Commercial |
$81.60
|
| Rate for Payer: Blue Shield of California EPN |
$81.60
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.00
|
| Rate for Payer: Dignity Health Senior |
$85.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.30
|
| Rate for Payer: Heritage Provider Network Senior |
$46.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$40.00
|
| Rate for Payer: TriValley Medical Group Senior |
$40.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.00
|
| Rate for Payer: Vantage Medical Group Senior |
$85.00
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 68094-494-61
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 68094-494-59
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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 |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 60687-743-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1828-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.11
|
| 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 |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 0121-1828-00
|
| 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: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 60687-743-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-2002-75
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care 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 |
$0.04
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| 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 |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 24385-905-26
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-2002-74
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care 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 |
$0.04
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| 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 |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-2002-75
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 68094-503-59
|
| 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: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 60687-743-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 68094-494-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| 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 |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 68094-503-62
|
| Hospital Charge Code |
901700029
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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 |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 68094-494-59
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| 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
|
|
