|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.29
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Riverside University Health System MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 6021915231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.37
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Central Health Plan Commercial |
$2.37
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
| Rate for Payer: Riverside University Health System MISP |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
| Rate for Payer: Riverside University Health System MISP |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 6021915231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.72
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Central Health Plan Commercial |
$2.37
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
| Rate for Payer: Riverside University Health System MISP |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| 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 |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| 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 |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| 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 |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$54.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.41
|
| Rate for Payer: Blue Shield of California Commercial |
$59.74
|
| Rate for Payer: Blue Shield of California EPN |
$37.65
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$80.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$66.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$45.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Riverside University Health System MISP |
$37.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Blue Shield of California Commercial |
$76.05
|
| Rate for Payer: Blue Shield of California EPN |
$47.79
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$66.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| 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 |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| 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 |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| 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
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| 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 |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| 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 |
$0.07
|
| 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 |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| 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 |
$0.07
|
| 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 |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 2780803301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 2780803301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 5224420010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Blue Shield of California Commercial |
$4.51
|
| Rate for Payer: Blue Shield of California EPN |
$2.84
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Central Health Plan Commercial |
$5.69
|
| Rate for Payer: Cigna of CA HMO |
$4.98
|
| Rate for Payer: Cigna of CA PPO |
$4.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.84
|
| Rate for Payer: EPIC Health Plan Senior |
$2.84
|
| Rate for Payer: Galaxy Health WC |
$6.04
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.98
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: Networks By Design Commercial |
$4.62
|
| Rate for Payer: Prime Health Services Commercial |
$6.04
|
| Rate for Payer: Riverside University Health System MISP |
$2.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3.56
|
| Rate for Payer: United Healthcare HMO Rider |
$3.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 5224420010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$5.70
|
| Rate for Payer: Blue Shield of California EPN |
$3.58
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Central Health Plan Commercial |
$5.69
|
| Rate for Payer: Cigna of CA HMO |
$4.98
|
| Rate for Payer: Cigna of CA PPO |
$4.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.84
|
| Rate for Payer: EPIC Health Plan Senior |
$2.84
|
| Rate for Payer: Galaxy Health WC |
$6.04
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: Networks By Design Commercial |
$4.62
|
| Rate for Payer: Prime Health Services Commercial |
$6.04
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
OP
|
$8.74
|
|
|
Service Code
|
NDC 5224430010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.08
|
| Rate for Payer: Blue Shield of California Commercial |
$5.54
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Central Health Plan Commercial |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$6.12
|
| Rate for Payer: Cigna of CA PPO |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Senior |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.43
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Networks By Design Commercial |
$5.68
|
| Rate for Payer: Prime Health Services Commercial |
$7.43
|
| Rate for Payer: Riverside University Health System MISP |
$3.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Other HMO |
$4.37
|
| Rate for Payer: United Healthcare HMO Rider |
$4.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.43
|
| Rate for Payer: Vantage Medical Group Senior |
$7.43
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
NDC 5224430010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$7.01
|
| Rate for Payer: Blue Shield of California EPN |
$4.40
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Central Health Plan Commercial |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$6.12
|
| Rate for Payer: Cigna of CA PPO |
$6.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.50
|
| Rate for Payer: EPIC Health Plan Senior |
$3.50
|
| Rate for Payer: Galaxy Health WC |
$7.43
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Networks By Design Commercial |
$5.68
|
| Rate for Payer: Prime Health Services Commercial |
$7.43
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 7257817301
|
| 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
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6233202531
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6846272101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6846272101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6233202531
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
