|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.35
|
| Rate for Payer: BCBS Transplant Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.90
|
| Rate for Payer: Blue Shield of California EPN |
$2.30
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Media |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Blue Shield of California Commercial |
$2.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
OP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.18
|
| Rate for Payer: BCBS Transplant Transplant |
$56.90
|
| Rate for Payer: Blue Shield of California Commercial |
$56.04
|
| Rate for Payer: Blue Shield of California EPN |
$44.48
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Media |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$71.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.42
|
| Rate for Payer: United Healthcare All Other HMO |
$47.42
|
| Rate for Payer: United Healthcare HMO Rider |
$47.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
IP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Blue Shield of California Commercial |
$67.52
|
| Rate for Payer: Blue Shield of California EPN |
$48.55
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
IP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Blue Shield of California Commercial |
$4.07
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
OP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.40
|
| Rate for Payer: BCBS Transplant Transplant |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$3.33
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.85
|
| Rate for Payer: Dignity Health Media |
$4.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$4.57
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare HMO Rider |
$2.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.85
|
| Rate for Payer: Vantage Medical Group Senior |
$4.85
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
OP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.18
|
| Rate for Payer: BCBS Transplant Transplant |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$5.17
|
| Rate for Payer: Blue Shield of California EPN |
$4.10
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna of CA HMO |
$4.91
|
| Rate for Payer: Cigna of CA PPO |
$4.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: Dignity Health Media |
$5.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$5.97
|
| Rate for Payer: Global Benefits Group Commercial |
$4.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.56
|
| Rate for Payer: Prime Health Services Commercial |
$5.97
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.51
|
| Rate for Payer: United Healthcare All Other HMO |
$3.51
|
| Rate for Payer: United Healthcare HMO Rider |
$3.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
IP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Blue Shield of California Commercial |
$5.00
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna of CA HMO |
$4.91
|
| Rate for Payer: Cigna of CA PPO |
$4.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$5.97
|
| Rate for Payer: Global Benefits Group Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.56
|
| Rate for Payer: Prime Health Services Commercial |
$5.97
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.45
|
| Rate for Payer: BCBS Transplant Transplant |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: Dignity Health Media |
$3.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.06
|
| Rate for Payer: United Healthcare HMO Rider |
$2.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.45
|
| Rate for Payer: BCBS Transplant Transplant |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: Dignity Health Media |
$3.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.06
|
| Rate for Payer: United Healthcare HMO Rider |
$2.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$3.30
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
IP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$3.71
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Prime Health Services Commercial |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
OP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: BCBS Transplant Transplant |
$2.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.71
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.94
|
| Rate for Payer: Dignity Health Media |
$3.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$3.71
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Prime Health Services Commercial |
$3.94
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2.32
|
| Rate for Payer: United Healthcare HMO Rider |
$2.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
OP
|
$1.61
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
ERX110533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: BCBS Transplant Transplant |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Media |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
