|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.04
|
|
|
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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| 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
|
|
|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| 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 Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals 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) CRUSHED PARTIAL TABLET [4081453]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| 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 |
$0.01
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| 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 |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 7733393425
|
| 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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7733393425
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| 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 |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
IP
|
$6.02
|
|
|
Service Code
|
NDC 9994080349
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4.63
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
OP
|
$6.02
|
|
|
Service Code
|
NDC 9994080349
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO |
$4.21
|
| Rate for Payer: Cigna of CA PPO |
$4.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.12
|
| Rate for Payer: Global Benefits Group Commercial |
$3.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.21
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: Networks By Design Commercial |
$3.91
|
| Rate for Payer: Prime Health Services Commercial |
$5.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.01
|
| Rate for Payer: United Healthcare All Other HMO |
$3.01
|
| Rate for Payer: United Healthcare HMO Rider |
$3.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Vantage Medical Group Senior |
$5.12
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 5107956601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 5107956601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
OP
|
$2,160.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$1,836.00 |
| Rate for Payer: Adventist Health Commercial |
$432.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,416.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.51
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Cigna of CA HMO |
$1,512.00
|
| Rate for Payer: Cigna of CA PPO |
$1,512.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,512.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.13
|
| Rate for Payer: EPIC Health Plan Senior |
$5.42
|
| Rate for Payer: Galaxy Health WC |
$1,836.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,296.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,371.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$518.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.61
|
| Rate for Payer: Multiplan Commercial |
$1,728.00
|
| Rate for Payer: Networks By Design Commercial |
$1,080.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,836.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,296.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,296.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$810.65
|
| Rate for Payer: United Healthcare All Other HMO |
$789.05
|
| Rate for Payer: United Healthcare HMO Rider |
$771.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$707.40
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Vantage Medical Group Senior |
$4.93
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
IP
|
$2,160.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$432.00 |
| Max. Negotiated Rate |
$1,836.00 |
| Rate for Payer: Adventist Health Commercial |
$432.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,095.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1,661.04
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Cigna of CA HMO |
$1,512.00
|
| Rate for Payer: Cigna of CA PPO |
$1,512.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,512.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$864.00
|
| Rate for Payer: EPIC Health Plan Senior |
$864.00
|
| Rate for Payer: Galaxy Health WC |
$1,836.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1,296.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,371.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,274.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$518.40
|
| Rate for Payer: Multiplan Commercial |
$1,728.00
|
| Rate for Payer: Networks By Design Commercial |
$1,080.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,836.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$810.65
|
| Rate for Payer: United Healthcare All Other HMO |
$789.05
|
| Rate for Payer: United Healthcare HMO Rider |
$771.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$707.40
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$137.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.51
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.13
|
| Rate for Payer: EPIC Health Plan Senior |
$5.42
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.61
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Vantage Medical Group Senior |
$4.93
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Blue Shield of California Commercial |
$106.47
|
| Rate for Payer: Blue Shield of California Commercial |
$161.49
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
IP
|
$85.86
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.17 |
| Max. Negotiated Rate |
$72.98 |
| Rate for Payer: Adventist Health Commercial |
$17.17
|
| Rate for Payer: Blue Shield of California Commercial |
$43.53
|
| Rate for Payer: Blue Shield of California Commercial |
$66.03
|
| Rate for Payer: Cash Price |
$38.64
|
| Rate for Payer: Cigna of CA HMO |
$60.10
|
| Rate for Payer: Cigna of CA PPO |
$60.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$60.10
|
| 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 Foundation Hospitals Commercial/Self Funded |
$54.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.61
|
| Rate for Payer: Multiplan Commercial |
$68.69
|
| Rate for Payer: Networks By Design Commercial |
$42.93
|
| Rate for Payer: Prime Health Services Commercial |
$72.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.22
|
| Rate for Payer: United Healthcare All Other HMO |
$31.36
|
| Rate for Payer: United Healthcare HMO Rider |
$30.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.12
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
OP
|
$85.86
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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: Cash Price |
$38.64
|
| Rate for Payer: Cigna of CA HMO |
$60.10
|
| Rate for Payer: Cigna of CA PPO |
$60.10
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$60.10
|
| 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 Foundation Hospitals Commercial/Self Funded |
$54.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.66
|
| 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 |
$42.93
|
| 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 |
$32.22
|
| Rate for Payer: United Healthcare All Other HMO |
$31.36
|
| Rate for Payer: United Healthcare HMO Rider |
$30.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.12
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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 |
$44.36
|
| Rate for Payer: Blue Shield of California Commercial |
$67.28
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cigna of CA HMO |
$61.24
|
| Rate for Payer: Cigna of CA PPO |
$61.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$61.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$55.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$51.62
|
| 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 |
$43.74
|
| Rate for Payer: Prime Health Services Commercial |
$74.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.83
|
| Rate for Payer: United Healthcare All Other HMO |
$31.96
|
| Rate for Payer: United Healthcare HMO Rider |
$31.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.65
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
OP
|
$87.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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: Cash Price |
$39.37
|
| Rate for Payer: Cigna of CA HMO |
$61.24
|
| Rate for Payer: Cigna of CA PPO |
$61.24
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$61.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$55.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$51.62
|
| 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 |
$43.74
|
| 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 |
$32.83
|
| Rate for Payer: United Healthcare All Other HMO |
$31.96
|
| Rate for Payer: United Healthcare HMO Rider |
$31.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.65
|
| 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(HUMAN)-FIBRINOGEN-APROTININ SYNTHETC-CALCIUM 4 ML TOPICAL KIT [221085]
|
Facility
|
OP
|
$382.67
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.53 |
| Max. Negotiated Rate |
$325.27 |
| Rate for Payer: Adventist Health Commercial |
$76.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$250.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$325.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$210.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$287.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$245.56
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna of CA HMO |
$267.87
|
| Rate for Payer: Cigna of CA PPO |
$267.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$325.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$325.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$325.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$267.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.07
|
| Rate for Payer: EPIC Health Plan Senior |
$153.07
|
| Rate for Payer: Galaxy Health WC |
$325.27
|
| Rate for Payer: Global Benefits Group Commercial |
$229.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$243.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$138.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$225.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$267.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$267.87
|
| Rate for Payer: Multiplan Commercial |
$306.14
|
| Rate for Payer: Networks By Design Commercial |
$191.34
|
| Rate for Payer: Prime Health Services Commercial |
$325.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$229.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$229.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.62
|
| Rate for Payer: United Healthcare All Other HMO |
$139.79
|
| Rate for Payer: United Healthcare HMO Rider |
$136.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$125.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$325.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$325.27
|
| Rate for Payer: Vantage Medical Group Senior |
$325.27
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYNTHETC-CALCIUM 4 ML TOPICAL KIT [221085]
|
Facility
|
IP
|
$382.67
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.53 |
| Max. Negotiated Rate |
$325.27 |
| Rate for Payer: Adventist Health Commercial |
$76.53
|
| Rate for Payer: Blue Shield of California Commercial |
$194.01
|
| Rate for Payer: Blue Shield of California Commercial |
$294.27
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna of CA HMO |
$267.87
|
| Rate for Payer: Cigna of CA PPO |
$267.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$267.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.07
|
| Rate for Payer: EPIC Health Plan Senior |
$153.07
|
| Rate for Payer: Galaxy Health WC |
$325.27
|
| Rate for Payer: Global Benefits Group Commercial |
$229.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$243.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$225.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.84
|
| Rate for Payer: Multiplan Commercial |
$306.14
|
| Rate for Payer: Networks By Design Commercial |
$191.34
|
| Rate for Payer: Prime Health Services Commercial |
$325.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$143.62
|
| Rate for Payer: United Healthcare All Other HMO |
$139.79
|
| Rate for Payer: United Healthcare HMO Rider |
$136.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$125.32
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338032401
|
| 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 |
$52.32
|
| Rate for Payer: Blue Shield of California Commercial |
$79.36
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$72.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$65.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.89
|
| 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 0338032201
|
| 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 |
$52.32
|
| Rate for Payer: Blue Shield of California Commercial |
$79.36
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$72.24
|
| 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 Foundation Hospitals Commercial/Self Funded |
$65.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.89
|
| 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
|
|
