|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
OP
|
$4.21
|
|
|
Service Code
|
NDC 50268-758-12
|
| Hospital Charge Code |
1710955
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.53
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.53
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.16
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
NDC 69097-533-02
|
| Hospital Charge Code |
1710955
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.86
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 50268-758-12
|
| Hospital Charge Code |
1710955
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.16
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
OP
|
$1.15
|
|
|
Service Code
|
NDC 69097-533-02
|
| Hospital Charge Code |
1710955
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.69
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.86
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 59746-383-06
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 59746-383-06
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 51079-936-20
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 51079-936-01
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 51079-936-01
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
TERAZOSIN 1 MG CAPSULE [14550]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 51079-936-20
|
| Hospital Charge Code |
1711490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.21
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 59746-384-10
|
| Hospital Charge Code |
1711491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 59746-384-10
|
| Hospital Charge Code |
1711491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 59746-384-06
|
| Hospital Charge Code |
1711491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 2 MG CAPSULE [14551]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 59746-384-06
|
| Hospital Charge Code |
1711491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 59746-385-06
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 50268-766-11
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 59746-385-06
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 50268-766-11
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 50268-766-15
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
TERAZOSIN 5 MG CAPSULE [14553]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 50268-766-15
|
| Hospital Charge Code |
1712151
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.76
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 24385-524-03
|
| Hospital Charge Code |
NDG27023B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 51672-2080-1
|
| Hospital Charge Code |
NDG27023
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.39
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 8770140472
|
| Hospital Charge Code |
NDG27023B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.30
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 24385-524-05
|
| Hospital Charge Code |
NDG27023
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 24385-524-05
|
| Hospital Charge Code |
NDG27023
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.41
|
|
