|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
IP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.29 |
| Max. Negotiated Rate |
$1,123.73 |
| Rate for Payer: Blue Shield of California Commercial |
$941.29
|
| Rate for Payer: Blue Shield of California EPN |
$676.88
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO |
$925.43
|
| Rate for Payer: Cigna of CA PPO |
$925.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$528.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$528.82
|
| Rate for Payer: Galaxy Health WC |
$1,123.73
|
| Rate for Payer: Global Benefits Group Commercial |
$793.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$881.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$503.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$317.29
|
| Rate for Payer: Multiplan Commercial |
$1,057.63
|
| Rate for Payer: Networks By Design Commercial |
$661.02
|
| Rate for Payer: Prime Health Services Commercial |
$1,123.73
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
OP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.29 |
| Max. Negotiated Rate |
$6,860.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6,860.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,123.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$727.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$727.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,727.59
|
| Rate for Payer: BCBS Transplant Transplant |
$793.22
|
| Rate for Payer: Blue Shield of California Commercial |
$974.34
|
| Rate for Payer: Blue Shield of California EPN |
$1,144.21
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO |
$925.43
|
| Rate for Payer: Cigna of CA PPO |
$925.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,123.73
|
| Rate for Payer: Dignity Health Media |
$1,123.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,123.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$528.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$528.82
|
| Rate for Payer: Galaxy Health WC |
$1,123.73
|
| Rate for Payer: Global Benefits Group Commercial |
$793.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$991.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$881.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,197.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$317.29
|
| Rate for Payer: Multiplan Commercial |
$1,057.63
|
| Rate for Payer: Networks By Design Commercial |
$661.02
|
| Rate for Payer: Prime Health Services Commercial |
$1,123.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$793.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$793.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$661.02
|
| Rate for Payer: United Healthcare All Other HMO |
$661.02
|
| Rate for Payer: United Healthcare HMO Rider |
$661.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$661.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,123.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,123.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1,123.73
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
IP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$96.39 |
| Rate for Payer: Blue Shield of California Commercial |
$80.74
|
| Rate for Payer: Blue Shield of California EPN |
$58.06
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: Galaxy Health WC |
$96.39
|
| Rate for Payer: Global Benefits Group Commercial |
$68.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.22
|
| Rate for Payer: Multiplan Commercial |
$90.72
|
| Rate for Payer: Networks By Design Commercial |
$73.71
|
| Rate for Payer: Prime Health Services Commercial |
$96.39
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
OP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.70
|
| Rate for Payer: Vantage Medical Group Senior |
$107.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$83.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$107.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.49
|
| Rate for Payer: BCBS Transplant Transplant |
$76.02
|
| Rate for Payer: Blue Shield of California Commercial |
$93.38
|
| Rate for Payer: Blue Shield of California EPN |
$73.99
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO |
$81.09
|
| Rate for Payer: Cigna of CA PPO |
$93.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.70
|
| Rate for Payer: Dignity Health Media |
$107.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.68
|
| Rate for Payer: Galaxy Health WC |
$107.70
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$95.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$101.36
|
| Rate for Payer: Networks By Design Commercial |
$82.36
|
| Rate for Payer: Prime Health Services Commercial |
$107.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$76.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$76.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$63.35
|
| Rate for Payer: United Healthcare All Other HMO |
$63.35
|
| Rate for Payer: United Healthcare HMO Rider |
$63.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$63.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
OP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$83.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$107.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.49
|
| Rate for Payer: BCBS Transplant Transplant |
$76.02
|
| Rate for Payer: Blue Shield of California Commercial |
$93.38
|
| Rate for Payer: Blue Shield of California EPN |
$73.99
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO |
$81.09
|
| Rate for Payer: Cigna of CA PPO |
$93.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.70
|
| Rate for Payer: Dignity Health Media |
$107.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.68
|
| Rate for Payer: Galaxy Health WC |
$107.70
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$95.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$101.36
|
| Rate for Payer: Networks By Design Commercial |
$82.36
|
| Rate for Payer: Prime Health Services Commercial |
$107.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$76.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$76.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$63.35
|
| Rate for Payer: United Healthcare All Other HMO |
$63.35
|
| Rate for Payer: United Healthcare HMO Rider |
$63.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$63.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.70
|
| Rate for Payer: Vantage Medical Group Senior |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
IP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Blue Shield of California Commercial |
$90.21
|
| Rate for Payer: Blue Shield of California EPN |
$64.87
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: Galaxy Health WC |
$107.70
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$101.36
|
| Rate for Payer: Networks By Design Commercial |
$82.36
|
| Rate for Payer: Prime Health Services Commercial |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
IP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.41 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Blue Shield of California Commercial |
$90.21
|
| Rate for Payer: Blue Shield of California EPN |
$64.87
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: Galaxy Health WC |
$107.70
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$84.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.41
|
| Rate for Payer: Multiplan Commercial |
$101.36
|
| Rate for Payer: Networks By Design Commercial |
$82.36
|
| Rate for Payer: Prime Health Services Commercial |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
OP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$96.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$74.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$62.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.56
|
| Rate for Payer: BCBS Transplant Transplant |
$68.04
|
| Rate for Payer: Blue Shield of California Commercial |
$83.58
|
| Rate for Payer: Blue Shield of California EPN |
$66.23
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna of CA HMO |
$72.58
|
| Rate for Payer: Cigna of CA PPO |
$83.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Media |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$45.36
|
| Rate for Payer: Galaxy Health WC |
$96.39
|
| Rate for Payer: Global Benefits Group Commercial |
$68.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$85.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.22
|
| Rate for Payer: Multiplan Commercial |
$90.72
|
| Rate for Payer: Networks By Design Commercial |
$73.71
|
| Rate for Payer: Prime Health Services Commercial |
$96.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.70
|
| Rate for Payer: United Healthcare All Other HMO |
$56.70
|
| Rate for Payer: United Healthcare HMO Rider |
$56.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$56.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 68180-969-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-11
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 0527-3284-46
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Media |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 68180-969-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Media |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 0074-6624-90
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-11
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Media |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| 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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.43
|
| Rate for Payer: BCBS Transplant Transplant |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Media |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.43
|
| 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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 0074-6624-90
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.07
|
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Media |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 72305-100-30
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| 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 Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| 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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.13
|
|
|
Service Code
|
NDC 0527-3284-46
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 72305-100-30
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.08
|
| 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: 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: 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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 42292-039-20
|
| Hospital Charge Code |
1711498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| 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: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 42292-039-01
|
| Hospital Charge Code |
1711498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| 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: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.57
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 68180-970-01
|
| Hospital Charge Code |
1711498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| 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
|
|
