|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Blue Shield of California Commercial |
$5.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.69
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Blue Shield of California Commercial |
$2.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.91
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.18
|
| Rate for Payer: Global Benefits Group Commercial |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.99
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$3.18
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.23
|
| Rate for Payer: Blue Distinction Transplant |
$2.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.76
|
| Rate for Payer: Blue Shield of California EPN |
$2.18
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.18
|
| Rate for Payer: Dignity Health Media |
$3.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.18
|
| Rate for Payer: Global Benefits Group Commercial |
$2.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.99
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$3.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO |
$1.87
|
| Rate for Payer: United Healthcare HMO Rider |
$1.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3.18
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
|
OP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$38.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.15
|
| Rate for Payer: Blue Distinction Transplant |
$27.34
|
| Rate for Payer: Blue Shield of California Commercial |
$33.59
|
| Rate for Payer: Blue Shield of California EPN |
$26.61
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Cigna of CA HMO |
$29.16
|
| Rate for Payer: Cigna of CA PPO |
$33.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.73
|
| Rate for Payer: Dignity Health Media |
$38.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.23
|
| Rate for Payer: Galaxy Health WC |
$38.73
|
| Rate for Payer: Global Benefits Group Commercial |
$27.34
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$34.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.94
|
| Rate for Payer: Multiplan Commercial |
$36.46
|
| Rate for Payer: Networks By Design Commercial |
$29.62
|
| Rate for Payer: Prime Health Services Commercial |
$38.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.78
|
| Rate for Payer: United Healthcare All Other HMO |
$22.78
|
| Rate for Payer: United Healthcare HMO Rider |
$22.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.73
|
| Rate for Payer: Vantage Medical Group Senior |
$38.73
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$38.73 |
| Rate for Payer: Blue Shield of California Commercial |
$32.45
|
| Rate for Payer: Blue Shield of California EPN |
$23.33
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: Galaxy Health WC |
$38.73
|
| Rate for Payer: Global Benefits Group Commercial |
$27.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.94
|
| Rate for Payer: Multiplan Commercial |
$36.46
|
| Rate for Payer: Networks By Design Commercial |
$29.62
|
| Rate for Payer: Prime Health Services Commercial |
$38.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Distinction Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.30
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Media |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Distinction Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.30
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Media |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: Blue Distinction Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.30
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Media |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Blue Shield of California Commercial |
$67.52
|
| Rate for Payer: Blue Shield of California EPN |
$48.55
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.81
|
| Rate for Payer: United Healthcare All Other HMO |
$34.97
|
| Rate for Payer: United Healthcare HMO Rider |
$34.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.29
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.18
|
| Rate for Payer: Blue Distinction Transplant |
$56.90
|
| Rate for Payer: Blue Shield of California Commercial |
$56.04
|
| Rate for Payer: Blue Shield of California EPN |
$44.48
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Media |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$71.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.42
|
| Rate for Payer: United Healthcare All Other HMO |
$47.42
|
| Rate for Payer: United Healthcare HMO Rider |
$47.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| 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 |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| 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 |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
IP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Blue Shield of California Commercial |
$4.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
OP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.40
|
| Rate for Payer: Blue Distinction Transplant |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$3.33
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.85
|
| Rate for Payer: Dignity Health Media |
$4.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare HMO Rider |
$2.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.85
|
| Rate for Payer: Vantage Medical Group Senior |
$4.85
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Blue Shield of California Commercial |
$5.00
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna of CA HMO |
$4.91
|
| Rate for Payer: Cigna of CA PPO |
$4.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$5.97
|
| Rate for Payer: Global Benefits Group Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.56
|
| Rate for Payer: Prime Health Services Commercial |
$5.97
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
OP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.18
|
| Rate for Payer: Blue Distinction Transplant |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$5.17
|
| Rate for Payer: Blue Shield of California EPN |
$4.10
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna of CA HMO |
$4.91
|
| Rate for Payer: Cigna of CA PPO |
$4.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: Dignity Health Media |
$5.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$5.97
|
| Rate for Payer: Global Benefits Group Commercial |
$4.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.56
|
| Rate for Payer: Prime Health Services Commercial |
$5.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.51
|
| Rate for Payer: United Healthcare All Other HMO |
$3.51
|
| Rate for Payer: United Healthcare HMO Rider |
$3.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
