|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| Hospital Charge Code |
ERX4081453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Distinction Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Distinction Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
THIOGUANINE 40 MG TABLET [7886]
|
Facility
|
OP
|
$30.33
|
|
|
Service Code
|
NDC 76388-880-25
|
| Hospital Charge Code |
1711149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$25.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.07
|
| Rate for Payer: Blue Distinction Transplant |
$18.20
|
| Rate for Payer: Blue Shield of California Commercial |
$22.35
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$13.65
|
| Rate for Payer: Cigna of CA HMO |
$21.23
|
| Rate for Payer: Cigna of CA PPO |
$21.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.78
|
| Rate for Payer: Dignity Health Media |
$25.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.13
|
| Rate for Payer: Galaxy Health WC |
$25.78
|
| Rate for Payer: Global Benefits Group Commercial |
$18.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$22.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.28
|
| Rate for Payer: Multiplan Commercial |
$24.26
|
| Rate for Payer: Networks By Design Commercial |
$19.71
|
| Rate for Payer: Prime Health Services Commercial |
$25.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.16
|
| Rate for Payer: United Healthcare All Other HMO |
$15.16
|
| Rate for Payer: United Healthcare HMO Rider |
$15.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: Vantage Medical Group Senior |
$25.78
|
|
|
THIOGUANINE 40 MG TABLET [7886]
|
Facility
|
IP
|
$30.33
|
|
|
Service Code
|
NDC 76388-880-25
|
| Hospital Charge Code |
1711149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$25.78 |
| Rate for Payer: Blue Shield of California Commercial |
$21.59
|
| Rate for Payer: Blue Shield of California EPN |
$15.53
|
| Rate for Payer: Cash Price |
$13.65
|
| Rate for Payer: Cigna of CA HMO |
$21.23
|
| Rate for Payer: Cigna of CA PPO |
$21.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.13
|
| Rate for Payer: Galaxy Health WC |
$25.78
|
| Rate for Payer: Global Benefits Group Commercial |
$18.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.28
|
| Rate for Payer: Multiplan Commercial |
$24.26
|
| Rate for Payer: Networks By Design Commercial |
$19.71
|
| Rate for Payer: Prime Health Services Commercial |
$25.78
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
1715020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Blue Shield of California Commercial |
$4.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.09
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
1715020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.59
|
| Rate for Payer: Blue Distinction Transplant |
$3.62
|
| Rate for Payer: Blue Shield of California Commercial |
$4.44
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Media |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
1710344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Distinction Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
1710344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
IP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,353.60 |
| Max. Negotiated Rate |
$4,794.00 |
| Rate for Payer: Blue Shield of California Commercial |
$4,015.68
|
| Rate for Payer: Blue Shield of California EPN |
$2,887.68
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO |
$3,948.00
|
| Rate for Payer: Cigna of CA PPO |
$3,948.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,256.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,256.00
|
| Rate for Payer: Galaxy Health WC |
$4,794.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,384.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,761.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,148.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.60
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: Networks By Design Commercial |
$2,820.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,794.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,129.66
|
| Rate for Payer: United Healthcare All Other HMO |
$2,080.03
|
| Rate for Payer: United Healthcare HMO Rider |
$2,034.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,861.20
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
OP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$218.83 |
| Max. Negotiated Rate |
$4,794.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$494.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$218.83
|
| Rate for Payer: Blue Distinction Transplant |
$3,384.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,156.68
|
| Rate for Payer: Blue Shield of California EPN |
$801.75
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO |
$3,948.00
|
| Rate for Payer: Cigna of CA PPO |
$3,948.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Media |
$251.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$339.13
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$251.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$251.20
|
| Rate for Payer: Galaxy Health WC |
$4,794.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,384.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4,230.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$411.98
|
| Rate for Payer: Heritage Provider Network Transplant |
$411.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$406.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$406.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,761.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$485.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$336.61
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: Networks By Design Commercial |
$2,820.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,794.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,384.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,384.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,820.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,820.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,820.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
1755061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$801.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$494.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$218.83
|
| Rate for Payer: Blue Distinction Transplant |
$540.00
|
| Rate for Payer: Blue Shield of California Commercial |
$663.30
|
| Rate for Payer: Blue Shield of California EPN |
$801.75
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO |
$630.00
|
| Rate for Payer: Cigna of CA PPO |
$630.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Media |
$251.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$339.13
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$251.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$251.20
|
| Rate for Payer: Galaxy Health WC |
$765.00
|
| Rate for Payer: Global Benefits Group Commercial |
$540.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$675.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$411.98
|
| Rate for Payer: Heritage Provider Network Transplant |
$411.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$406.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$406.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$600.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$485.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$336.61
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$450.00
|
| Rate for Payer: Prime Health Services Commercial |
$765.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$540.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$540.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$450.00
|
| Rate for Payer: United Healthcare All Other HMO |
$450.00
|
| Rate for Payer: United Healthcare HMO Rider |
$450.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$450.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
1755061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Blue Shield of California Commercial |
$640.80
|
| Rate for Payer: Blue Shield of California EPN |
$460.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO |
$630.00
|
| Rate for Payer: Cigna of CA PPO |
$630.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$360.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$360.00
|
| Rate for Payer: Galaxy Health WC |
$765.00
|
| Rate for Payer: Global Benefits Group Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$600.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$342.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$450.00
|
| Rate for Payer: Prime Health Services Commercial |
$765.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Other HMO |
$331.92
|
| Rate for Payer: United Healthcare HMO Rider |
$324.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.00
|
|
|
THIOTHIXENE 2 MG CAPSULE [7904]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 51079-587-01
|
| Hospital Charge Code |
1711269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: Blue Distinction Transplant |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Media |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
THIOTHIXENE 2 MG CAPSULE [7904]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 51079-587-01
|
| Hospital Charge Code |
1711269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.67
|
| Rate for Payer: Cigna of CA PPO |
$1.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: Networks By Design Commercial |
$1.55
|
| Rate for Payer: Prime Health Services Commercial |
$2.03
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
OP
|
$80.93
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
NDG221104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.42 |
| Max. Negotiated Rate |
$68.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.22
|
| Rate for Payer: Blue Distinction Transplant |
$48.56
|
| Rate for Payer: Blue Shield of California Commercial |
$59.65
|
| Rate for Payer: Blue Shield of California EPN |
$47.26
|
| Rate for Payer: Cash Price |
$36.42
|
| Rate for Payer: Cigna of CA HMO |
$51.80
|
| Rate for Payer: Cigna of CA PPO |
$59.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.79
|
| Rate for Payer: Dignity Health Media |
$68.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.37
|
| Rate for Payer: Galaxy Health WC |
$68.79
|
| Rate for Payer: Global Benefits Group Commercial |
$48.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$60.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.42
|
| Rate for Payer: Multiplan Commercial |
$64.74
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$68.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$48.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$48.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.46
|
| Rate for Payer: United Healthcare All Other HMO |
$40.46
|
| Rate for Payer: United Healthcare HMO Rider |
$40.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$40.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$68.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.79
|
| Rate for Payer: Vantage Medical Group Senior |
$68.79
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
IP
|
$80.93
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
NDG221104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.42 |
| Max. Negotiated Rate |
$68.79 |
| Rate for Payer: Blue Shield of California Commercial |
$57.62
|
| Rate for Payer: Blue Shield of California EPN |
$41.44
|
| Rate for Payer: Cash Price |
$36.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.37
|
| Rate for Payer: Galaxy Health WC |
$68.79
|
| Rate for Payer: Global Benefits Group Commercial |
$48.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$53.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.42
|
| Rate for Payer: Multiplan Commercial |
$64.74
|
| Rate for Payer: Networks By Design Commercial |
$52.60
|
| Rate for Payer: Prime Health Services Commercial |
$68.79
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
IP
|
$82.46
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
NDG221103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.79 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Blue Shield of California Commercial |
$58.71
|
| Rate for Payer: Blue Shield of California EPN |
$42.22
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.98
|
| Rate for Payer: Galaxy Health WC |
$70.09
|
| Rate for Payer: Global Benefits Group Commercial |
$49.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$65.97
|
| Rate for Payer: Networks By Design Commercial |
$53.60
|
| Rate for Payer: Prime Health Services Commercial |
$70.09
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
OP
|
$82.46
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
NDG221103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.79 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$70.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.13
|
| Rate for Payer: Blue Distinction Transplant |
$49.48
|
| Rate for Payer: Blue Shield of California Commercial |
$60.77
|
| Rate for Payer: Blue Shield of California EPN |
$48.16
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cigna of CA HMO |
$52.77
|
| Rate for Payer: Cigna of CA PPO |
$61.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.09
|
| Rate for Payer: Dignity Health Media |
$70.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.98
|
| Rate for Payer: Galaxy Health WC |
$70.09
|
| Rate for Payer: Global Benefits Group Commercial |
$49.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$61.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.79
|
| Rate for Payer: Multiplan Commercial |
$65.97
|
| Rate for Payer: Networks By Design Commercial |
$53.60
|
| Rate for Payer: Prime Health Services Commercial |
$70.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.23
|
| Rate for Payer: United Healthcare All Other HMO |
$41.23
|
| Rate for Payer: United Healthcare HMO Rider |
$41.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$70.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.09
|
| Rate for Payer: Vantage Medical Group Senior |
$70.09
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.77 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Blue Shield of California Commercial |
$73.48
|
| Rate for Payer: Blue Shield of California EPN |
$52.84
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.77 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Blue Shield of California Commercial |
$73.48
|
| Rate for Payer: Blue Shield of California EPN |
$52.84
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.77 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.49
|
| Rate for Payer: Blue Distinction Transplant |
$61.92
|
| Rate for Payer: Blue Shield of California Commercial |
$76.06
|
| Rate for Payer: Blue Shield of California EPN |
$60.27
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Cigna of CA HMO |
$66.05
|
| Rate for Payer: Cigna of CA PPO |
$76.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Media |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$77.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.60
|
| Rate for Payer: United Healthcare All Other HMO |
$51.60
|
| Rate for Payer: United Healthcare HMO Rider |
$51.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.77 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.49
|
| Rate for Payer: Blue Distinction Transplant |
$61.92
|
| Rate for Payer: Blue Shield of California Commercial |
$76.06
|
| Rate for Payer: Blue Shield of California EPN |
$60.27
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Cigna of CA HMO |
$66.05
|
| Rate for Payer: Cigna of CA PPO |
$76.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Media |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$77.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.60
|
| Rate for Payer: United Healthcare All Other HMO |
$51.60
|
| Rate for Payer: United Healthcare HMO Rider |
$51.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
