LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
OP
|
$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: Aetna of CA HMO/PPO |
$0.47
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.39
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
Rate for Payer: BCBS Transplant Transplant |
$0.43
|
Rate for Payer: Blue Shield of California Commercial |
$0.52
|
Rate for Payer: Blue Shield of California EPN |
$0.41
|
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 |
$0.60
|
Rate for Payer: Dignity Health Media |
$0.60
|
Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
Rate for Payer: Galaxy Health WC |
$0.60
|
Rate for Payer: Global Benefits Group Commercial |
$0.43
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.53
|
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
|
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 |
$0.60
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
IP
|
$0.40
|
|
Service Code
|
NDC 69238-1835-1
|
Hospital Charge Code |
1711498
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Blue Shield of California Commercial |
$0.28
|
Rate for Payer: Blue Shield of California EPN |
$0.20
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.28
|
Rate for Payer: Cigna of CA PPO |
$0.28
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: Galaxy Health WC |
$0.34
|
Rate for Payer: Global Benefits Group Commercial |
$0.24
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.32
|
Rate for Payer: Networks By Design Commercial |
$0.26
|
Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
OP
|
$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: BCBS Transplant Transplant |
$0.43
|
Rate for Payer: Aetna of CA HMO/PPO |
$0.47
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.39
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
Rate for Payer: Blue Shield of California Commercial |
$0.52
|
Rate for Payer: Blue Shield of California EPN |
$0.41
|
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 |
$0.60
|
Rate for Payer: Dignity Health Media |
$0.60
|
Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
Rate for Payer: Galaxy Health WC |
$0.60
|
Rate for Payer: Global Benefits Group Commercial |
$0.43
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.53
|
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
|
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 |
$0.60
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
IP
|
$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: 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 |
$0.14
|
Rate for Payer: Cigna of CA PPO |
$0.14
|
Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
Rate for Payer: Galaxy Health WC |
$0.17
|
Rate for Payer: Global Benefits Group Commercial |
$0.12
|
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
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
OP
|
$0.40
|
|
Service Code
|
NDC 69238-1835-1
|
Hospital Charge Code |
1711498
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Galaxy Health WC |
$0.34
|
Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
Rate for Payer: BCBS Transplant Transplant |
$0.24
|
Rate for Payer: Blue Shield of California Commercial |
$0.29
|
Rate for Payer: Blue Shield of California EPN |
$0.23
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.28
|
Rate for Payer: Cigna of CA PPO |
$0.28
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
Rate for Payer: Dignity Health Media |
$0.34
|
Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
Rate for Payer: Global Benefits Group Commercial |
$0.24
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.32
|
Rate for Payer: Networks By Design Commercial |
$0.26
|
Rate for Payer: Prime Health Services Commercial |
$0.34
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
Rate for Payer: United Healthcare All Other HMO |
$0.20
|
Rate for Payer: United Healthcare HMO Rider |
$0.20
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
IP
|
$0.40
|
|
Service Code
|
NDC 69238-1836-1
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Blue Shield of California Commercial |
$0.28
|
Rate for Payer: Blue Shield of California EPN |
$0.20
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.28
|
Rate for Payer: Cigna of CA PPO |
$0.28
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: Galaxy Health WC |
$0.34
|
Rate for Payer: Global Benefits Group Commercial |
$0.24
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.32
|
Rate for Payer: Networks By Design Commercial |
$0.26
|
Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
OP
|
$0.40
|
|
Service Code
|
NDC 69238-1836-1
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.34 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
Rate for Payer: BCBS Transplant Transplant |
$0.24
|
Rate for Payer: Blue Shield of California Commercial |
$0.29
|
Rate for Payer: Blue Shield of California EPN |
$0.23
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.28
|
Rate for Payer: Cigna of CA PPO |
$0.28
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
Rate for Payer: Dignity Health Media |
$0.34
|
Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
Rate for Payer: Galaxy Health WC |
$0.34
|
Rate for Payer: Global Benefits Group Commercial |
$0.24
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.32
|
Rate for Payer: Networks By Design Commercial |
$0.26
|
Rate for Payer: Prime Health Services Commercial |
$0.34
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
Rate for Payer: United Healthcare All Other HMO |
$0.20
|
Rate for Payer: United Healthcare HMO Rider |
$0.20
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
OP
|
$0.23
|
|
Service Code
|
NDC 68180-971-09
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.06 |
Max. Negotiated Rate |
$0.20 |
Rate for Payer: BCBS Transplant Transplant |
$0.14
|
Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
Rate for Payer: Blue Shield of California Commercial |
$0.17
|
Rate for Payer: Blue Shield of California EPN |
$0.13
|
Rate for Payer: Cash Price |
$0.10
|
Rate for Payer: Cigna of CA HMO |
$0.16
|
Rate for Payer: Cigna of CA PPO |
$0.16
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
Rate for Payer: Dignity Health Media |
$0.20
|
Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
Rate for Payer: Galaxy Health WC |
$0.20
|
Rate for Payer: Global Benefits Group Commercial |
$0.14
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
Rate for Payer: Multiplan Commercial |
$0.18
|
Rate for Payer: Networks By Design Commercial |
$0.15
|
Rate for Payer: Prime Health Services Commercial |
$0.20
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.14
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
Rate for Payer: United Healthcare All Other HMO |
$0.12
|
Rate for Payer: United Healthcare HMO Rider |
$0.12
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
OP
|
$0.16
|
|
Service Code
|
NDC 0527-3286-46
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.14 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
Rate for Payer: BCBS Transplant Transplant |
$0.10
|
Rate for Payer: Blue Shield of California Commercial |
$0.12
|
Rate for Payer: Blue Shield of California EPN |
$0.09
|
Rate for Payer: Cash Price |
$0.07
|
Rate for Payer: Cigna of CA HMO |
$0.11
|
Rate for Payer: Cigna of CA PPO |
$0.11
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
Rate for Payer: Dignity Health Media |
$0.14
|
Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
Rate for Payer: Galaxy Health WC |
$0.14
|
Rate for Payer: Global Benefits Group Commercial |
$0.10
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.12
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
Rate for Payer: Multiplan Commercial |
$0.13
|
Rate for Payer: Networks By Design Commercial |
$0.10
|
Rate for Payer: Prime Health Services Commercial |
$0.14
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
Rate for Payer: United Healthcare All Other HMO |
$0.08
|
Rate for Payer: United Healthcare HMO Rider |
$0.08
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
IP
|
$0.16
|
|
Service Code
|
NDC 0527-3286-46
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.14 |
Rate for Payer: Blue Shield of California Commercial |
$0.11
|
Rate for Payer: Blue Shield of California EPN |
$0.08
|
Rate for Payer: Cash Price |
$0.07
|
Rate for Payer: Cigna of CA HMO |
$0.11
|
Rate for Payer: Cigna of CA PPO |
$0.11
|
Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
Rate for Payer: Galaxy Health WC |
$0.14
|
Rate for Payer: Global Benefits Group Commercial |
$0.10
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
Rate for Payer: Multiplan Commercial |
$0.13
|
Rate for Payer: Networks By Design Commercial |
$0.10
|
Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
IP
|
$0.23
|
|
Service Code
|
NDC 68180-971-09
|
Hospital Charge Code |
1710638
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.06 |
Max. Negotiated Rate |
$0.20 |
Rate for Payer: Blue Shield of California Commercial |
$0.16
|
Rate for Payer: Blue Shield of California EPN |
$0.12
|
Rate for Payer: Cash Price |
$0.10
|
Rate for Payer: Cigna of CA HMO |
$0.16
|
Rate for Payer: Cigna of CA PPO |
$0.16
|
Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
Rate for Payer: Galaxy Health WC |
$0.20
|
Rate for Payer: Global Benefits Group Commercial |
$0.14
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
Rate for Payer: Multiplan Commercial |
$0.18
|
Rate for Payer: Networks By Design Commercial |
$0.15
|
Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
OP
|
$0.86
|
|
Service Code
|
NDC 60687-563-01
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.73 |
Rate for Payer: BCBS Transplant Transplant |
$0.52
|
Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
Rate for Payer: Blue Shield of California Commercial |
$0.63
|
Rate for Payer: Blue Shield of California EPN |
$0.50
|
Rate for Payer: Cash Price |
$0.39
|
Rate for Payer: Cigna of CA HMO |
$0.60
|
Rate for Payer: Cigna of CA PPO |
$0.60
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
Rate for Payer: Dignity Health Media |
$0.73
|
Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
Rate for Payer: Galaxy Health WC |
$0.73
|
Rate for Payer: Global Benefits Group Commercial |
$0.52
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.65
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.69
|
Rate for Payer: Networks By Design Commercial |
$0.56
|
Rate for Payer: Prime Health Services Commercial |
$0.73
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.52
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
Rate for Payer: United Healthcare All Other HMO |
$0.43
|
Rate for Payer: United Healthcare HMO Rider |
$0.43
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
OP
|
$0.86
|
|
Service Code
|
NDC 60687-563-11
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.73 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
Rate for Payer: BCBS Transplant Transplant |
$0.52
|
Rate for Payer: Blue Shield of California Commercial |
$0.63
|
Rate for Payer: Blue Shield of California EPN |
$0.50
|
Rate for Payer: Cash Price |
$0.39
|
Rate for Payer: Cigna of CA HMO |
$0.60
|
Rate for Payer: Cigna of CA PPO |
$0.60
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
Rate for Payer: Dignity Health Media |
$0.73
|
Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
Rate for Payer: EPIC Health Plan Transplant |
$0.34
|
Rate for Payer: Galaxy Health WC |
$0.73
|
Rate for Payer: Global Benefits Group Commercial |
$0.52
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.65
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.69
|
Rate for Payer: Networks By Design Commercial |
$0.56
|
Rate for Payer: Prime Health Services Commercial |
$0.73
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.52
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
Rate for Payer: United Healthcare All Other Commercial |
$0.43
|
Rate for Payer: United Healthcare All Other HMO |
$0.43
|
Rate for Payer: United Healthcare HMO Rider |
$0.43
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.73
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
OP
|
$0.73
|
|
Service Code
|
NDC 42292-041-01
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.62 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.48
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.62
|
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 |
$0.44
|
Rate for Payer: Blue Shield of California Commercial |
$0.54
|
Rate for Payer: Blue Shield of California EPN |
$0.43
|
Rate for Payer: Cash Price |
$0.33
|
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 Media |
$0.62
|
Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
Rate for Payer: Galaxy Health WC |
$0.62
|
Rate for Payer: Global Benefits Group Commercial |
$0.44
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.55
|
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: 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
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.44
|
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
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
IP
|
$0.86
|
|
Service Code
|
NDC 60687-563-11
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.73 |
Rate for Payer: Blue Shield of California Commercial |
$0.61
|
Rate for Payer: Blue Shield of California EPN |
$0.44
|
Rate for Payer: Cash Price |
$0.39
|
Rate for Payer: Cigna of CA HMO |
$0.60
|
Rate for Payer: Cigna of CA PPO |
$0.60
|
Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
Rate for Payer: Galaxy Health WC |
$0.73
|
Rate for Payer: Global Benefits Group Commercial |
$0.52
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.69
|
Rate for Payer: Networks By Design Commercial |
$0.56
|
Rate for Payer: Prime Health Services Commercial |
$0.73
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
IP
|
$0.73
|
|
Service Code
|
NDC 42292-041-20
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.62 |
Rate for Payer: Blue Shield of California Commercial |
$0.52
|
Rate for Payer: Blue Shield of California EPN |
$0.37
|
Rate for Payer: Cash Price |
$0.33
|
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: 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: 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
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
IP
|
$0.86
|
|
Service Code
|
NDC 60687-563-01
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.73 |
Rate for Payer: Blue Shield of California Commercial |
$0.61
|
Rate for Payer: Blue Shield of California EPN |
$0.44
|
Rate for Payer: Cash Price |
$0.39
|
Rate for Payer: Cigna of CA HMO |
$0.60
|
Rate for Payer: Cigna of CA PPO |
$0.60
|
Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
Rate for Payer: Galaxy Health WC |
$0.73
|
Rate for Payer: Global Benefits Group Commercial |
$0.52
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.57
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.69
|
Rate for Payer: Networks By Design Commercial |
$0.56
|
Rate for Payer: Prime Health Services Commercial |
$0.73
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
IP
|
$0.73
|
|
Service Code
|
NDC 42292-041-01
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.62 |
Rate for Payer: Blue Shield of California Commercial |
$0.52
|
Rate for Payer: Blue Shield of California EPN |
$0.37
|
Rate for Payer: Cash Price |
$0.33
|
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: 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: 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
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
IP
|
$0.41
|
|
Service Code
|
NDC 69238-1837-1
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.35 |
Rate for Payer: Blue Shield of California Commercial |
$0.29
|
Rate for Payer: Blue Shield of California EPN |
$0.21
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.29
|
Rate for Payer: Cigna of CA PPO |
$0.29
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: Galaxy Health WC |
$0.35
|
Rate for Payer: Global Benefits Group Commercial |
$0.25
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.33
|
Rate for Payer: Networks By Design Commercial |
$0.27
|
Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
OP
|
$0.41
|
|
Service Code
|
NDC 69238-1837-1
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.35 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
Rate for Payer: BCBS Transplant Transplant |
$0.25
|
Rate for Payer: Blue Shield of California Commercial |
$0.30
|
Rate for Payer: Blue Shield of California EPN |
$0.24
|
Rate for Payer: Cash Price |
$0.18
|
Rate for Payer: Cigna of CA HMO |
$0.29
|
Rate for Payer: Cigna of CA PPO |
$0.29
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
Rate for Payer: Dignity Health Media |
$0.35
|
Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
Rate for Payer: Galaxy Health WC |
$0.35
|
Rate for Payer: Global Benefits Group Commercial |
$0.25
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.31
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
Rate for Payer: Multiplan Commercial |
$0.33
|
Rate for Payer: Networks By Design Commercial |
$0.27
|
Rate for Payer: Prime Health Services Commercial |
$0.35
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
Rate for Payer: United Healthcare All Other HMO |
$0.21
|
Rate for Payer: United Healthcare HMO Rider |
$0.21
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
LEVOTHYROXINE 137 MCG TABLET [10405]
|
Facility
OP
|
$0.18
|
|
Service Code
|
NDC 0527-3287-46
|
Hospital Charge Code |
1710965
|
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 137 MCG TABLET [10405]
|
Facility
IP
|
$0.18
|
|
Service Code
|
NDC 0527-3287-46
|
Hospital Charge Code |
1710965
|
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 137 MCG TABLET [10405]
|
Facility
OP
|
$0.73
|
|
Service Code
|
NDC 42292-041-20
|
Hospital Charge Code |
1710965
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.62 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.48
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.62
|
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 |
$0.44
|
Rate for Payer: Blue Shield of California Commercial |
$0.54
|
Rate for Payer: Blue Shield of California EPN |
$0.43
|
Rate for Payer: Cash Price |
$0.33
|
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 Media |
$0.62
|
Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
Rate for Payer: EPIC Health Plan Transplant |
$0.29
|
Rate for Payer: Galaxy Health WC |
$0.62
|
Rate for Payer: Global Benefits Group Commercial |
$0.44
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.55
|
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: 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
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.44
|
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
|
|
LEVOTHYROXINE 150 MCG TABLET [4425]
|
Facility
IP
|
$0.88
|
|
Service Code
|
NDC 60687-530-11
|
Hospital Charge Code |
1710626
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$0.75 |
Rate for Payer: Blue Shield of California Commercial |
$0.63
|
Rate for Payer: Blue Shield of California EPN |
$0.45
|
Rate for Payer: Cash Price |
$0.40
|
Rate for Payer: Cigna of CA HMO |
$0.62
|
Rate for Payer: Cigna of CA PPO |
$0.62
|
Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
Rate for Payer: Galaxy Health WC |
$0.75
|
Rate for Payer: Global Benefits Group Commercial |
$0.53
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.59
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
Rate for Payer: Multiplan Commercial |
$0.70
|
Rate for Payer: Networks By Design Commercial |
$0.57
|
Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
LEVOTHYROXINE 150 MCG TABLET [4425]
|
Facility
IP
|
$0.16
|
|
Service Code
|
NDC 47781-662-90
|
Hospital Charge Code |
1710626
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.14 |
Rate for Payer: Blue Shield of California Commercial |
$0.11
|
Rate for Payer: Blue Shield of California EPN |
$0.08
|
Rate for Payer: Cash Price |
$0.07
|
Rate for Payer: Cigna of CA HMO |
$0.11
|
Rate for Payer: Cigna of CA PPO |
$0.11
|
Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
Rate for Payer: Galaxy Health WC |
$0.14
|
Rate for Payer: Global Benefits Group Commercial |
$0.10
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
Rate for Payer: Multiplan Commercial |
$0.13
|
Rate for Payer: Networks By Design Commercial |
$0.10
|
Rate for Payer: Prime Health Services Commercial |
$0.14
|
|