|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0555902058
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0555902079
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0555902058
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
IP
|
$1,526.93
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$305.39 |
| Max. Negotiated Rate |
$1,374.24 |
| Rate for Payer: Adventist Health Commercial |
$305.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1,224.60
|
| Rate for Payer: Blue Shield of California EPN |
$769.57
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Central Health Plan Commercial |
$1,221.54
|
| Rate for Payer: Cigna of CA HMO |
$1,068.85
|
| Rate for Payer: Cigna of CA PPO |
$1,068.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,068.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$610.77
|
| Rate for Payer: EPIC Health Plan Senior |
$610.77
|
| Rate for Payer: Galaxy Health WC |
$1,297.89
|
| Rate for Payer: Global Benefits Group Commercial |
$916.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,374.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$969.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$900.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$305.39
|
| Rate for Payer: Multiplan Commercial |
$1,145.20
|
| Rate for Payer: Networks By Design Commercial |
$763.47
|
| Rate for Payer: Prime Health Services Commercial |
$1,297.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$573.06
|
| Rate for Payer: United Healthcare All Other HMO |
$557.79
|
| Rate for Payer: United Healthcare HMO Rider |
$545.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$500.07
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
OP
|
$1,526.93
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$305.39 |
| Max. Negotiated Rate |
$7,452.61 |
| Rate for Payer: Adventist Health Commercial |
$305.39
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7,452.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$839.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,145.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,698.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,119.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1,526.96
|
| Rate for Payer: Blue Shield of California EPN |
$1,388.15
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Central Health Plan Commercial |
$1,221.54
|
| Rate for Payer: Cigna of CA HMO |
$1,068.85
|
| Rate for Payer: Cigna of CA PPO |
$1,068.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,297.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,297.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,068.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$610.77
|
| Rate for Payer: EPIC Health Plan Senior |
$610.77
|
| Rate for Payer: Galaxy Health WC |
$1,297.89
|
| Rate for Payer: Global Benefits Group Commercial |
$916.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,374.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,188.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$969.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,417.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$900.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$305.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,068.85
|
| Rate for Payer: Multiplan Commercial |
$1,145.20
|
| Rate for Payer: Networks By Design Commercial |
$763.47
|
| Rate for Payer: Prime Health Services Commercial |
$1,297.89
|
| Rate for Payer: Riverside University Health System MISP |
$610.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$916.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$916.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$573.06
|
| Rate for Payer: United Healthcare All Other HMO |
$557.79
|
| Rate for Payer: United Healthcare HMO Rider |
$545.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$500.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,297.89
|
| Rate for Payer: Vantage Medical Group Senior |
$1,297.89
|
|
|
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
IP
|
$1,173.98
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.80 |
| Max. Negotiated Rate |
$1,056.58 |
| Rate for Payer: Adventist Health Commercial |
$234.80
|
| Rate for Payer: Blue Shield of California Commercial |
$941.53
|
| Rate for Payer: Blue Shield of California EPN |
$591.69
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Central Health Plan Commercial |
$939.18
|
| Rate for Payer: Cigna of CA HMO |
$821.79
|
| Rate for Payer: Cigna of CA PPO |
$821.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$821.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$469.59
|
| Rate for Payer: EPIC Health Plan Senior |
$469.59
|
| Rate for Payer: Galaxy Health WC |
$997.88
|
| Rate for Payer: Global Benefits Group Commercial |
$704.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,056.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$745.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$692.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$234.80
|
| Rate for Payer: Multiplan Commercial |
$880.49
|
| Rate for Payer: Networks By Design Commercial |
$586.99
|
| Rate for Payer: Prime Health Services Commercial |
$997.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$440.59
|
| Rate for Payer: United Healthcare All Other HMO |
$428.85
|
| Rate for Payer: United Healthcare HMO Rider |
$419.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$384.48
|
|
|
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
OP
|
$1,173.98
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.80 |
| Max. Negotiated Rate |
$5,716.82 |
| Rate for Payer: Adventist Health Commercial |
$234.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5,716.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$997.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$645.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$880.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,236.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,543.61
|
| Rate for Payer: Blue Shield of California Commercial |
$1,171.31
|
| Rate for Payer: Blue Shield of California EPN |
$1,064.83
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Central Health Plan Commercial |
$939.18
|
| Rate for Payer: Cigna of CA HMO |
$821.79
|
| Rate for Payer: Cigna of CA PPO |
$821.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$997.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$997.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$997.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$821.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$469.59
|
| Rate for Payer: EPIC Health Plan Senior |
$469.59
|
| Rate for Payer: Galaxy Health WC |
$997.88
|
| Rate for Payer: Global Benefits Group Commercial |
$704.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,056.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,602.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$745.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,770.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$692.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$234.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$821.79
|
| Rate for Payer: Multiplan Commercial |
$880.49
|
| Rate for Payer: Networks By Design Commercial |
$586.99
|
| Rate for Payer: Prime Health Services Commercial |
$997.88
|
| Rate for Payer: Riverside University Health System MISP |
$469.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$704.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$704.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$440.59
|
| Rate for Payer: United Healthcare All Other HMO |
$428.85
|
| Rate for Payer: United Healthcare HMO Rider |
$419.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$384.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$997.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$997.88
|
| Rate for Payer: Vantage Medical Group Senior |
$997.88
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.68 |
| Max. Negotiated Rate |
$102.06 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Blue Shield of California Commercial |
$90.95
|
| Rate for Payer: Blue Shield of California Commercial |
$88.36
|
| Rate for Payer: Blue Shield of California Commercial |
$115.83
|
| Rate for Payer: Blue Shield of California Commercial |
$101.61
|
| Rate for Payer: Blue Shield of California EPN |
$57.15
|
| Rate for Payer: Blue Shield of California EPN |
$55.53
|
| Rate for Payer: Blue Shield of California EPN |
$63.86
|
| Rate for Payer: Blue Shield of California EPN |
$72.79
|
| Rate for Payer: Cash Price |
$64.99
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Central Health Plan Commercial |
$115.54
|
| Rate for Payer: Central Health Plan Commercial |
$90.72
|
| Rate for Payer: Central Health Plan Commercial |
$88.14
|
| Rate for Payer: Central Health Plan Commercial |
$101.36
|
| Rate for Payer: Cigna of CA HMO |
$79.38
|
| Rate for Payer: Cigna of CA HMO |
$88.69
|
| Rate for Payer: Cigna of CA HMO |
$101.10
|
| Rate for Payer: Cigna of CA HMO |
$77.12
|
| Rate for Payer: Cigna of CA PPO |
$77.12
|
| Rate for Payer: Cigna of CA PPO |
$79.38
|
| Rate for Payer: Cigna of CA PPO |
$88.69
|
| Rate for Payer: Cigna of CA PPO |
$101.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$77.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$88.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.07
|
| Rate for Payer: EPIC Health Plan Senior |
$45.36
|
| Rate for Payer: EPIC Health Plan Senior |
$50.68
|
| Rate for Payer: EPIC Health Plan Senior |
$57.77
|
| Rate for Payer: EPIC Health Plan Senior |
$44.07
|
| Rate for Payer: Galaxy Health WC |
$107.69
|
| Rate for Payer: Galaxy Health WC |
$93.64
|
| Rate for Payer: Galaxy Health WC |
$96.39
|
| Rate for Payer: Galaxy Health WC |
$122.77
|
| Rate for Payer: Global Benefits Group Commercial |
$86.66
|
| Rate for Payer: Global Benefits Group Commercial |
$68.04
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Global Benefits Group Commercial |
$66.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$129.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$114.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$99.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$80.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$69.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$74.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Networks By Design Commercial |
$72.22
|
| Rate for Payer: Networks By Design Commercial |
$55.09
|
| Rate for Payer: Networks By Design Commercial |
$63.35
|
| Rate for Payer: Networks By Design Commercial |
$56.70
|
| Rate for Payer: Prime Health Services Commercial |
$107.69
|
| Rate for Payer: Prime Health Services Commercial |
$96.39
|
| Rate for Payer: Prime Health Services Commercial |
$93.64
|
| Rate for Payer: Prime Health Services Commercial |
$122.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.56
|
| Rate for Payer: United Healthcare All Other HMO |
$41.43
|
| Rate for Payer: United Healthcare All Other HMO |
$40.25
|
| Rate for Payer: United Healthcare All Other HMO |
$52.76
|
| Rate for Payer: United Healthcare All Other HMO |
$46.28
|
| Rate for Payer: United Healthcare HMO Rider |
$39.37
|
| Rate for Payer: United Healthcare HMO Rider |
$45.28
|
| Rate for Payer: United Healthcare HMO Rider |
$51.62
|
| Rate for Payer: United Healthcare HMO Rider |
$40.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.49
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$144.43
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$129.99 |
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$44.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$44.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$44.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$44.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$20.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$20.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$20.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$20.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.09
|
| Rate for Payer: Blue Shield of California Commercial |
$13.39
|
| Rate for Payer: Blue Shield of California Commercial |
$13.39
|
| Rate for Payer: Blue Shield of California Commercial |
$13.39
|
| Rate for Payer: Blue Shield of California Commercial |
$13.39
|
| Rate for Payer: Blue Shield of California EPN |
$12.17
|
| Rate for Payer: Blue Shield of California EPN |
$12.17
|
| Rate for Payer: Blue Shield of California EPN |
$12.17
|
| Rate for Payer: Blue Shield of California EPN |
$12.17
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$64.99
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$64.99
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Central Health Plan Commercial |
$88.14
|
| Rate for Payer: Central Health Plan Commercial |
$115.54
|
| Rate for Payer: Central Health Plan Commercial |
$101.36
|
| Rate for Payer: Central Health Plan Commercial |
$90.72
|
| Rate for Payer: Cigna of CA HMO |
$79.38
|
| Rate for Payer: Cigna of CA HMO |
$88.69
|
| Rate for Payer: Cigna of CA HMO |
$101.10
|
| Rate for Payer: Cigna of CA HMO |
$77.12
|
| Rate for Payer: Cigna of CA PPO |
$88.69
|
| Rate for Payer: Cigna of CA PPO |
$101.10
|
| Rate for Payer: Cigna of CA PPO |
$77.12
|
| Rate for Payer: Cigna of CA PPO |
$79.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$122.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$122.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$107.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$122.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$93.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$88.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$77.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.07
|
| Rate for Payer: EPIC Health Plan Senior |
$50.68
|
| Rate for Payer: EPIC Health Plan Senior |
$44.07
|
| Rate for Payer: EPIC Health Plan Senior |
$45.36
|
| Rate for Payer: EPIC Health Plan Senior |
$57.77
|
| Rate for Payer: Galaxy Health WC |
$122.77
|
| Rate for Payer: Galaxy Health WC |
$96.39
|
| Rate for Payer: Galaxy Health WC |
$107.69
|
| Rate for Payer: Galaxy Health WC |
$93.64
|
| Rate for Payer: Global Benefits Group Commercial |
$86.66
|
| Rate for Payer: Global Benefits Group Commercial |
$68.04
|
| Rate for Payer: Global Benefits Group Commercial |
$76.02
|
| Rate for Payer: Global Benefits Group Commercial |
$66.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$102.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$129.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$99.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$114.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$69.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$72.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$91.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$80.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$74.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$77.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$88.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.10
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: Networks By Design Commercial |
$72.22
|
| Rate for Payer: Networks By Design Commercial |
$56.70
|
| Rate for Payer: Networks By Design Commercial |
$63.35
|
| Rate for Payer: Networks By Design Commercial |
$55.09
|
| Rate for Payer: Prime Health Services Commercial |
$122.77
|
| Rate for Payer: Prime Health Services Commercial |
$107.69
|
| Rate for Payer: Prime Health Services Commercial |
$93.64
|
| Rate for Payer: Prime Health Services Commercial |
$96.39
|
| Rate for Payer: Riverside University Health System MISP |
$44.07
|
| Rate for Payer: Riverside University Health System MISP |
$45.36
|
| Rate for Payer: Riverside University Health System MISP |
$50.68
|
| Rate for Payer: Riverside University Health System MISP |
$57.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$86.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$66.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$76.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$66.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$86.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$76.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.20
|
| Rate for Payer: United Healthcare All Other HMO |
$52.76
|
| Rate for Payer: United Healthcare All Other HMO |
$46.28
|
| Rate for Payer: United Healthcare All Other HMO |
$40.25
|
| Rate for Payer: United Healthcare All Other HMO |
$41.43
|
| Rate for Payer: United Healthcare HMO Rider |
$45.28
|
| Rate for Payer: United Healthcare HMO Rider |
$39.37
|
| Rate for Payer: United Healthcare HMO Rider |
$40.53
|
| Rate for Payer: United Healthcare HMO Rider |
$51.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$122.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$122.77
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$107.69
|
| Rate for Payer: Vantage Medical Group Senior |
$93.64
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 1672945115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 6818096909
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 6923818341
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 7230510030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| 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: Health Management Network EPO/PPO |
$0.18
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 6923818341
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 6068749711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| 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
|
$0.20
|
|
|
Service Code
|
NDC 7230510030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| 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 |
$0.17
|
| 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 Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| 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: Health Management Network EPO/PPO |
$0.18
|
| 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 |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| 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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 1672945115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 6818096909
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 6068749701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0527328446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| 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
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 6068749701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Riverside University Health System MISP |
$0.29
|
| 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
|
$0.13
|
|
|
Service Code
|
NDC 0527328446
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| 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 Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| 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: Riverside University Health System MISP |
$0.05
|
| 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
|
$0.72
|
|
|
Service Code
|
NDC 6068749711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Riverside University Health System MISP |
$0.29
|
| 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 112 MCG TABLET [10404]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 4229203920
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Senior |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| 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
|
$0.40
|
|
|
Service Code
|
NDC 6923818351
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| 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 Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| 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
|
|
