|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
|
OP
|
$2,314.82
|
|
|
Service Code
|
CPT J3240
|
| Hospital Charge Code |
ERX24409
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$555.56 |
| Max. Negotiated Rate |
$12,712.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,712.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,526.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,223.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,223.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,059.63
|
| Rate for Payer: Blue Distinction Transplant |
$1,388.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1,706.02
|
| Rate for Payer: Blue Shield of California EPN |
$2,028.60
|
| Rate for Payer: Cash Price |
$1,041.67
|
| Rate for Payer: Cash Price |
$1,041.67
|
| Rate for Payer: Cigna of CA HMO |
$1,620.37
|
| Rate for Payer: Cigna of CA PPO |
$1,620.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,031.76
|
| Rate for Payer: Dignity Health Media |
$2,021.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,223.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,728.58
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,021.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,021.17
|
| Rate for Payer: Galaxy Health WC |
$1,967.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1,388.89
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,736.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,314.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,314.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,274.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,274.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,021.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,543.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,848.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,021.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$555.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,546.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,708.37
|
| Rate for Payer: Multiplan Commercial |
$1,851.86
|
| Rate for Payer: Networks By Design Commercial |
$1,157.41
|
| Rate for Payer: Prime Health Services Commercial |
$1,967.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,388.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,388.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,157.41
|
| Rate for Payer: United Healthcare All Other HMO |
$1,157.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1,157.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,157.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,031.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,223.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2,021.17
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
IP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
ERX211180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Blue Shield of California Commercial |
$6.24
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
ERX211180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.22
|
| Rate for Payer: Blue Distinction Transplant |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.46
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Media |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Blue Shield of California Commercial |
$6.24
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.22
|
| Rate for Payer: Blue Distinction Transplant |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.46
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Media |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.22
|
| Rate for Payer: Blue Distinction Transplant |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.46
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Media |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Blue Shield of California Commercial |
$6.24
|
| Rate for Payer: Blue Shield of California EPN |
$4.49
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO |
$6.13
|
| Rate for Payer: Cigna of CA PPO |
$6.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.45
|
| Rate for Payer: Global Benefits Group Commercial |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.01
|
| Rate for Payer: Networks By Design Commercial |
$5.69
|
| Rate for Payer: Prime Health Services Commercial |
$7.45
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
IP
|
$124.80
|
|
|
Service Code
|
CPT J3243
|
| Hospital Charge Code |
1753538
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.95 |
| Max. Negotiated Rate |
$106.08 |
| Rate for Payer: Blue Shield of California Commercial |
$88.86
|
| Rate for Payer: Blue Shield of California Commercial |
$135.73
|
| Rate for Payer: Blue Shield of California Commercial |
$51.26
|
| Rate for Payer: Blue Shield of California Commercial |
$89.71
|
| Rate for Payer: Blue Shield of California Commercial |
$106.97
|
| Rate for Payer: Blue Shield of California EPN |
$64.51
|
| Rate for Payer: Blue Shield of California EPN |
$76.92
|
| Rate for Payer: Blue Shield of California EPN |
$63.90
|
| Rate for Payer: Blue Shield of California EPN |
$36.86
|
| Rate for Payer: Blue Shield of California EPN |
$97.60
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA HMO |
$88.20
|
| Rate for Payer: Cigna of CA HMO |
$105.17
|
| Rate for Payer: Cigna of CA HMO |
$133.44
|
| Rate for Payer: Cigna of CA HMO |
$87.36
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$88.20
|
| Rate for Payer: Cigna of CA PPO |
$105.17
|
| Rate for Payer: Cigna of CA PPO |
$133.44
|
| Rate for Payer: Cigna of CA PPO |
$87.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.10
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Galaxy Health WC |
$107.10
|
| Rate for Payer: Galaxy Health WC |
$162.04
|
| Rate for Payer: Galaxy Health WC |
$127.70
|
| Rate for Payer: Galaxy Health WC |
$106.08
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Global Benefits Group Commercial |
$114.38
|
| Rate for Payer: Global Benefits Group Commercial |
$90.14
|
| Rate for Payer: Global Benefits Group Commercial |
$75.60
|
| Rate for Payer: Global Benefits Group Commercial |
$74.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$120.19
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: Multiplan Commercial |
$152.50
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Networks By Design Commercial |
$63.00
|
| Rate for Payer: Networks By Design Commercial |
$75.12
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Networks By Design Commercial |
$95.32
|
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Prime Health Services Commercial |
$162.04
|
| Rate for Payer: Prime Health Services Commercial |
$127.70
|
| Rate for Payer: Prime Health Services Commercial |
$106.08
|
| Rate for Payer: Prime Health Services Commercial |
$107.10
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.58
|
| Rate for Payer: United Healthcare All Other HMO |
$46.47
|
| Rate for Payer: United Healthcare All Other HMO |
$46.03
|
| Rate for Payer: United Healthcare All Other HMO |
$55.41
|
| Rate for Payer: United Healthcare All Other HMO |
$70.30
|
| Rate for Payer: United Healthcare All Other HMO |
$26.55
|
| Rate for Payer: United Healthcare HMO Rider |
$25.98
|
| Rate for Payer: United Healthcare HMO Rider |
$68.78
|
| Rate for Payer: United Healthcare HMO Rider |
$45.46
|
| Rate for Payer: United Healthcare HMO Rider |
$45.03
|
| Rate for Payer: United Healthcare HMO Rider |
$54.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.58
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT J3243
|
| Hospital Charge Code |
1753538
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$127.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$106.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$162.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$82.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$104.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$68.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Blue Distinction Transplant |
$90.14
|
| Rate for Payer: Blue Distinction Transplant |
$75.60
|
| Rate for Payer: Blue Distinction Transplant |
$74.88
|
| Rate for Payer: Blue Distinction Transplant |
$43.20
|
| Rate for Payer: Blue Distinction Transplant |
$114.38
|
| Rate for Payer: Blue Shield of California Commercial |
$53.06
|
| Rate for Payer: Blue Shield of California Commercial |
$110.73
|
| Rate for Payer: Blue Shield of California Commercial |
$91.98
|
| Rate for Payer: Blue Shield of California Commercial |
$140.49
|
| Rate for Payer: Blue Shield of California Commercial |
$92.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cigna of CA HMO |
$133.44
|
| Rate for Payer: Cigna of CA HMO |
$87.36
|
| Rate for Payer: Cigna of CA HMO |
$88.20
|
| Rate for Payer: Cigna of CA HMO |
$50.40
|
| Rate for Payer: Cigna of CA HMO |
$105.17
|
| Rate for Payer: Cigna of CA PPO |
$88.20
|
| Rate for Payer: Cigna of CA PPO |
$133.44
|
| Rate for Payer: Cigna of CA PPO |
$50.40
|
| Rate for Payer: Cigna of CA PPO |
$87.36
|
| Rate for Payer: Cigna of CA PPO |
$105.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.08
|
| Rate for Payer: Dignity Health Media |
$106.08
|
| Rate for Payer: Dignity Health Media |
$162.04
|
| Rate for Payer: Dignity Health Media |
$61.20
|
| Rate for Payer: Dignity Health Media |
$107.10
|
| Rate for Payer: Dignity Health Media |
$127.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$28.80
|
| Rate for Payer: Galaxy Health WC |
$107.10
|
| Rate for Payer: Galaxy Health WC |
$61.20
|
| Rate for Payer: Galaxy Health WC |
$127.70
|
| Rate for Payer: Galaxy Health WC |
$106.08
|
| Rate for Payer: Galaxy Health WC |
$162.04
|
| Rate for Payer: Global Benefits Group Commercial |
$114.38
|
| Rate for Payer: Global Benefits Group Commercial |
$90.14
|
| Rate for Payer: Global Benefits Group Commercial |
$43.20
|
| Rate for Payer: Global Benefits Group Commercial |
$74.88
|
| Rate for Payer: Global Benefits Group Commercial |
$75.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$142.97
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$54.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$93.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$112.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$94.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$83.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.95
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Multiplan Commercial |
$120.19
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: Multiplan Commercial |
$57.60
|
| Rate for Payer: Multiplan Commercial |
$152.50
|
| Rate for Payer: Networks By Design Commercial |
$36.00
|
| Rate for Payer: Networks By Design Commercial |
$75.12
|
| Rate for Payer: Networks By Design Commercial |
$95.32
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Networks By Design Commercial |
$63.00
|
| Rate for Payer: Prime Health Services Commercial |
$162.04
|
| Rate for Payer: Prime Health Services Commercial |
$127.70
|
| Rate for Payer: Prime Health Services Commercial |
$106.08
|
| Rate for Payer: Prime Health Services Commercial |
$107.10
|
| Rate for Payer: Prime Health Services Commercial |
$61.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$43.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$75.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$74.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$74.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$75.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$63.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Other HMO |
$62.40
|
| Rate for Payer: United Healthcare All Other HMO |
$75.12
|
| Rate for Payer: United Healthcare All Other HMO |
$63.00
|
| Rate for Payer: United Healthcare All Other HMO |
$95.32
|
| Rate for Payer: United Healthcare All Other HMO |
$36.00
|
| Rate for Payer: United Healthcare HMO Rider |
$62.40
|
| Rate for Payer: United Healthcare HMO Rider |
$95.32
|
| Rate for Payer: United Healthcare HMO Rider |
$36.00
|
| Rate for Payer: United Healthcare HMO Rider |
$75.12
|
| Rate for Payer: United Healthcare HMO Rider |
$63.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$63.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$127.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$106.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$162.04
|
| Rate for Payer: Vantage Medical Group Senior |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$127.70
|
| Rate for Payer: Vantage Medical Group Senior |
$106.08
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Blue Distinction Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Media |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
NDG11561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Distinction Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Media |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: Blue Distinction Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Media |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.88
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
NDG11561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Distinction Transplant |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.63
|
| Rate for Payer: Cigna of CA PPO |
$1.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.98
|
| Rate for Payer: Dignity Health Media |
$1.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.93
|
| Rate for Payer: Galaxy Health WC |
$1.98
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.86
|
| Rate for Payer: Networks By Design Commercial |
$1.51
|
| Rate for Payer: Prime Health Services Commercial |
$1.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1.16
|
| Rate for Payer: United Healthcare HMO Rider |
$1.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.19
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$1.62
|
| Rate for Payer: Cigna of CA PPO |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Galaxy Health WC |
$1.97
|
| Rate for Payer: Global Benefits Group Commercial |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.86
|
| Rate for Payer: Networks By Design Commercial |
$1.51
|
| Rate for Payer: Prime Health Services Commercial |
$1.97
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Distinction Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Media |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Blue Shield of California Commercial |
$1.66
|
| Rate for Payer: Blue Shield of California EPN |
$1.19
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$1.63
|
| Rate for Payer: Cigna of CA PPO |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Galaxy Health WC |
$1.98
|
| Rate for Payer: Global Benefits Group Commercial |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.86
|
| Rate for Payer: Networks By Design Commercial |
$1.51
|
| Rate for Payer: Prime Health Services Commercial |
$1.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: Blue Distinction Transplant |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$1.62
|
| Rate for Payer: Cigna of CA PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.97
|
| Rate for Payer: Dignity Health Media |
$1.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.93
|
| Rate for Payer: Galaxy Health WC |
$1.97
|
| Rate for Payer: Global Benefits Group Commercial |
$1.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.86
|
| Rate for Payer: Networks By Design Commercial |
$1.51
|
| Rate for Payer: Prime Health Services Commercial |
$1.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1.16
|
| Rate for Payer: United Healthcare HMO Rider |
$1.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: Vantage Medical Group Senior |
$1.97
|
|
|
TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]
|
Facility
|
OP
|
$24.34
|
|
|
Service Code
|
NDC 0597-0075-75
|
| Hospital Charge Code |
1744109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.50
|
| Rate for Payer: Blue Distinction Transplant |
$14.60
|
| Rate for Payer: Blue Shield of California Commercial |
$17.94
|
| Rate for Payer: Blue Shield of California EPN |
$14.21
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: Cigna of CA HMO |
$17.04
|
| Rate for Payer: Cigna of CA PPO |
$17.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.69
|
| Rate for Payer: Dignity Health Media |
$20.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.74
|
| Rate for Payer: Galaxy Health WC |
$20.69
|
| Rate for Payer: Global Benefits Group Commercial |
$14.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$18.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.84
|
| Rate for Payer: Multiplan Commercial |
$19.47
|
| Rate for Payer: Networks By Design Commercial |
$15.82
|
| Rate for Payer: Prime Health Services Commercial |
$20.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.17
|
| Rate for Payer: United Healthcare All Other HMO |
$12.17
|
| Rate for Payer: United Healthcare HMO Rider |
$12.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.69
|
| Rate for Payer: Vantage Medical Group Senior |
$20.69
|
|
|
TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]
|
Facility
|
IP
|
$24.34
|
|
|
Service Code
|
NDC 0597-0075-75
|
| Hospital Charge Code |
1744109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Blue Shield of California Commercial |
$17.33
|
| Rate for Payer: Blue Shield of California EPN |
$12.46
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: Cigna of CA HMO |
$17.04
|
| Rate for Payer: Cigna of CA PPO |
$17.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.74
|
| Rate for Payer: Galaxy Health WC |
$20.69
|
| Rate for Payer: Global Benefits Group Commercial |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.84
|
| Rate for Payer: Multiplan Commercial |
$19.47
|
| Rate for Payer: Networks By Design Commercial |
$15.82
|
| Rate for Payer: Prime Health Services Commercial |
$20.69
|
|
|
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
NDC 0597-0100-51
|
| Hospital Charge Code |
ERX207738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$19.12 |
| Rate for Payer: Blue Shield of California Commercial |
$16.02
|
| Rate for Payer: Blue Shield of California EPN |
$11.52
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Global Benefits Group Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Networks By Design Commercial |
$14.62
|
| Rate for Payer: Prime Health Services Commercial |
$19.12
|
|
|
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
NDC 0597-0100-51
|
| Hospital Charge Code |
ERX207738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$19.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.41
|
| Rate for Payer: Blue Distinction Transplant |
$13.50
|
| Rate for Payer: Blue Shield of California Commercial |
$16.58
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO |
$15.75
|
| Rate for Payer: Cigna of CA PPO |
$15.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.12
|
| Rate for Payer: Dignity Health Media |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.00
|
| Rate for Payer: Galaxy Health WC |
$19.12
|
| Rate for Payer: Global Benefits Group Commercial |
$13.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.40
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Networks By Design Commercial |
$14.62
|
| Rate for Payer: Prime Health Services Commercial |
$19.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.25
|
| Rate for Payer: United Healthcare All Other HMO |
$11.25
|
| Rate for Payer: United Healthcare HMO Rider |
$11.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.12
|
| Rate for Payer: Vantage Medical Group Senior |
$19.12
|
|
