|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
OP
|
$85.86
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.17 |
| Max. Negotiated Rate |
$72.98 |
| Rate for Payer: Adventist Health Commercial |
$17.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$56.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.73
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cigna of CA HMO |
$54.95
|
| Rate for Payer: Cigna of CA PPO |
$63.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$72.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.34
|
| Rate for Payer: EPIC Health Plan Senior |
$34.34
|
| Rate for Payer: Galaxy Health WC |
$72.98
|
| Rate for Payer: Global Benefits Group Commercial |
$51.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$57.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.10
|
| Rate for Payer: Multiplan Commercial |
$68.69
|
| Rate for Payer: Networks By Design Commercial |
$55.81
|
| Rate for Payer: Prime Health Services Commercial |
$72.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$51.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$51.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.93
|
| Rate for Payer: United Healthcare All Other HMO |
$42.93
|
| Rate for Payer: United Healthcare HMO Rider |
$42.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.98
|
| Rate for Payer: Vantage Medical Group Senior |
$72.98
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
IP
|
$87.49
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$74.37 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Blue Shield of California Commercial |
$64.57
|
| Rate for Payer: Blue Shield of California EPN |
$42.52
|
| Rate for Payer: Cash Price |
$48.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.00
|
| Rate for Payer: EPIC Health Plan Senior |
$35.00
|
| Rate for Payer: Galaxy Health WC |
$74.37
|
| Rate for Payer: Global Benefits Group Commercial |
$52.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$54.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$69.99
|
| Rate for Payer: Networks By Design Commercial |
$56.87
|
| Rate for Payer: Prime Health Services Commercial |
$74.37
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
OP
|
$87.49
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$74.37 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$57.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.73
|
| Rate for Payer: Cash Price |
$48.12
|
| Rate for Payer: Cigna of CA HMO |
$55.99
|
| Rate for Payer: Cigna of CA PPO |
$64.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$74.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.00
|
| Rate for Payer: EPIC Health Plan Senior |
$35.00
|
| Rate for Payer: Galaxy Health WC |
$74.37
|
| Rate for Payer: Global Benefits Group Commercial |
$52.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$54.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$61.24
|
| Rate for Payer: Multiplan Commercial |
$69.99
|
| Rate for Payer: Networks By Design Commercial |
$56.87
|
| Rate for Payer: Prime Health Services Commercial |
$74.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$52.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$52.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.74
|
| Rate for Payer: United Healthcare All Other HMO |
$43.74
|
| Rate for Payer: United Healthcare HMO Rider |
$43.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$43.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.37
|
| Rate for Payer: Vantage Medical Group Senior |
$74.37
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$67.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.38
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Cigna of CA HMO |
$66.05
|
| Rate for Payer: Cigna of CA PPO |
$76.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.24
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.60
|
| Rate for Payer: United Healthcare All Other HMO |
$51.60
|
| Rate for Payer: United Healthcare HMO Rider |
$51.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California Commercial |
$76.16
|
| Rate for Payer: Blue Shield of California EPN |
$50.16
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California Commercial |
$76.16
|
| Rate for Payer: Blue Shield of California EPN |
$50.16
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$67.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$63.38
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Cigna of CA HMO |
$66.05
|
| Rate for Payer: Cigna of CA PPO |
$76.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.24
|
| Rate for Payer: Multiplan Commercial |
$82.56
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.60
|
| Rate for Payer: United Healthcare All Other HMO |
$51.60
|
| Rate for Payer: United Healthcare HMO Rider |
$51.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 75834-310-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 75834-310-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.62
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$1.85
|
| Rate for Payer: Cigna of CA PPO |
$1.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Senior |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.72
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$1.85
|
| Rate for Payer: Cigna of CA PPO |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: EPIC Health Plan Senior |
$1.06
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.72
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.03
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.50
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.70
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.45
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare HMO Rider |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.51
|
| Rate for Payer: Cigna of CA PPO |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.62
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.62
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO |
$0.68
|
| Rate for Payer: United Healthcare HMO Rider |
$0.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.95
|
| Rate for Payer: Cigna of CA PPO |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.15
|
|
