|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Blue Shield of California Commercial |
$69.98
|
| Rate for Payer: Blue Shield of California EPN |
$46.09
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$58.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 |
$0.06
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.06
|
| 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 27808-033-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
OP
|
$6.90
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.24
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cigna of CA HMO |
$4.83
|
| Rate for Payer: Cigna of CA PPO |
$4.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Senior |
$2.76
|
| Rate for Payer: Galaxy Health WC |
$5.87
|
| Rate for Payer: Global Benefits Group Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.83
|
| Rate for Payer: Multiplan Commercial |
$5.52
|
| Rate for Payer: Networks By Design Commercial |
$4.49
|
| Rate for Payer: Prime Health Services Commercial |
$5.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.45
|
| Rate for Payer: United Healthcare All Other HMO |
$3.45
|
| Rate for Payer: United Healthcare HMO Rider |
$3.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.87
|
| Rate for Payer: Vantage Medical Group Senior |
$5.87
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
IP
|
$6.90
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.38
|
| Rate for Payer: Blue Shield of California Commercial |
$5.09
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cigna of CA HMO |
$4.83
|
| Rate for Payer: Cigna of CA PPO |
$4.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Senior |
$2.76
|
| Rate for Payer: Galaxy Health WC |
$5.87
|
| Rate for Payer: Global Benefits Group Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.66
|
| Rate for Payer: Multiplan Commercial |
$5.52
|
| Rate for Payer: Networks By Design Commercial |
$4.49
|
| Rate for Payer: Prime Health Services Commercial |
$5.87
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
IP
|
$8.48
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$6.26
|
| Rate for Payer: Blue Shield of California EPN |
$4.12
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: EPIC Health Plan Senior |
$3.39
|
| Rate for Payer: Galaxy Health WC |
$7.21
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.78
|
| Rate for Payer: Networks By Design Commercial |
$5.51
|
| Rate for Payer: Prime Health Services Commercial |
$7.21
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
OP
|
$8.48
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.21
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO |
$5.94
|
| Rate for Payer: Cigna of CA PPO |
$5.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.39
|
| Rate for Payer: EPIC Health Plan Senior |
$3.39
|
| Rate for Payer: Galaxy Health WC |
$7.21
|
| Rate for Payer: Global Benefits Group Commercial |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.78
|
| Rate for Payer: Networks By Design Commercial |
$5.51
|
| Rate for Payer: Prime Health Services Commercial |
$7.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Other HMO |
$4.24
|
| Rate for Payer: United Healthcare HMO Rider |
$4.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.21
|
| Rate for Payer: Vantage Medical Group Senior |
$7.21
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 72578-173-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| 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
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 72578-173-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| 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 |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.40
|
| 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 Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| 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
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.85
|
| Rate for Payer: Cash Price |
$2.55
|
| 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 Medi-Cal |
$3.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| 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: 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 CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$2.55
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$2.87
|
| 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 TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
OP
|
$5.12
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$8.92 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of CA HMO |
$4.18
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA HMO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$4.18
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.49
|
| Rate for Payer: EPIC Health Plan Senior |
$2.39
|
| Rate for Payer: Galaxy Health WC |
$4.35
|
| Rate for Payer: Galaxy Health WC |
$5.07
|
| Rate for Payer: Galaxy Health WC |
$3.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Global Benefits Group Commercial |
$2.23
|
| Rate for Payer: Global Benefits Group Commercial |
$3.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Multiplan Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$1.86
|
| Rate for Payer: Prime Health Services Commercial |
$5.07
|
| Rate for Payer: Prime Health Services Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1.33
|
| Rate for Payer: United Healthcare HMO Rider |
$2.13
|
| Rate for Payer: United Healthcare HMO Rider |
$1.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$3.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$4.35
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.75
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$2.90
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA HMO |
$2.60
|
| Rate for Payer: Cigna of CA HMO |
$4.18
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$2.60
|
| Rate for Payer: Cigna of CA PPO |
$4.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: EPIC Health Plan Senior |
$2.39
|
| Rate for Payer: EPIC Health Plan Senior |
$1.49
|
| Rate for Payer: EPIC Health Plan Senior |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.35
|
| Rate for Payer: Galaxy Health WC |
$3.16
|
| Rate for Payer: Galaxy Health WC |
$5.07
|
| Rate for Payer: Global Benefits Group Commercial |
$3.58
|
| Rate for Payer: Global Benefits Group Commercial |
$2.23
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$2.98
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Multiplan Commercial |
$4.78
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$1.86
|
| Rate for Payer: Prime Health Services Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.35
|
| Rate for Payer: Prime Health Services Commercial |
$5.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.24
|
| Rate for Payer: United Healthcare All Other HMO |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO |
$1.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1.87
|
| Rate for Payer: United Healthcare HMO Rider |
$1.83
|
| Rate for Payer: United Healthcare HMO Rider |
$2.13
|
| Rate for Payer: United Healthcare HMO Rider |
$1.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.68
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0904719106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| 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 |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0904719106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
