|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 42658-115-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 67877-491-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$100.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$43.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$75.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$75.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$43.20
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$57.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$100.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$75.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$43.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$69.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.60
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
|
|
TIMOLOL 0.5 % EYE DROPS [15115]
|
Facility
|
IP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS [15115]
|
Facility
|
OP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.46
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.46
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.39
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.39
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
