|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 0456045901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$1.14
|
| Rate for Payer: Cigna of CA HMO |
$0.99
|
| Rate for Payer: Cigna of CA PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: Networks By Design Commercial |
$0.92
|
| Rate for Payer: Prime Health Services Commercial |
$1.21
|
| Rate for Payer: Riverside University Health System MISP |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.71
|
| Rate for Payer: United Healthcare All Other HMO |
$0.71
|
| Rate for Payer: United Healthcare HMO Rider |
$0.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Vantage Medical Group Senior |
$1.21
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 4219233001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 7583431201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.69
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.69
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 7583431201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.65
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.69
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 4219233030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.64
|
| Rate for Payer: Cigna of CA PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.78
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
|
OP
|
$2,475.08
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$495.02 |
| Max. Negotiated Rate |
$12,881.90 |
| Rate for Payer: Adventist Health Commercial |
$495.02
|
| Rate for Payer: Adventist Health Medi-Cal |
$2,158.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12,881.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,374.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,374.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$983.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,227.78
|
| Rate for Payer: Blue Shield of California Commercial |
$2,609.96
|
| Rate for Payer: Blue Shield of California EPN |
$2,372.69
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Central Health Plan Commercial |
$1,980.06
|
| Rate for Payer: Cigna of CA HMO |
$1,732.56
|
| Rate for Payer: Cigna of CA PPO |
$1,732.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,374.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,374.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,732.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,561.79
|
| Rate for Payer: EPIC Health Plan Senior |
$2,374.53
|
| Rate for Payer: Galaxy Health WC |
$2,103.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1,485.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,227.57
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,540.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2,158.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,158.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,571.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,047.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,022.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$495.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,892.60
|
| Rate for Payer: Multiplan Commercial |
$1,856.31
|
| Rate for Payer: Networks By Design Commercial |
$1,237.54
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,158.66
|
| Rate for Payer: Prime Health Services Commercial |
$2,103.82
|
| Rate for Payer: Prime Health Services Medicare |
$2,288.18
|
| Rate for Payer: Riverside University Health System MISP |
$2,374.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,485.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,485.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$928.90
|
| Rate for Payer: United Healthcare All Other HMO |
$904.15
|
| Rate for Payer: United Healthcare HMO Rider |
$884.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$810.59
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,158.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,374.53
|
| Rate for Payer: Vantage Medical Group Senior |
$2,374.53
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
|
IP
|
$2,475.08
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$495.02 |
| Max. Negotiated Rate |
$2,227.57 |
| Rate for Payer: Adventist Health Commercial |
$495.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1,985.01
|
| Rate for Payer: Blue Shield of California EPN |
$1,247.44
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Central Health Plan Commercial |
$1,980.06
|
| Rate for Payer: Cigna of CA HMO |
$1,732.56
|
| Rate for Payer: Cigna of CA PPO |
$1,732.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,732.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$990.03
|
| Rate for Payer: EPIC Health Plan Senior |
$990.03
|
| Rate for Payer: Galaxy Health WC |
$2,103.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1,485.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,227.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,571.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,460.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$495.02
|
| Rate for Payer: Multiplan Commercial |
$1,856.31
|
| Rate for Payer: Networks By Design Commercial |
$1,237.54
|
| Rate for Payer: Prime Health Services Commercial |
$2,103.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$928.90
|
| Rate for Payer: United Healthcare All Other HMO |
$904.15
|
| Rate for Payer: United Healthcare HMO Rider |
$884.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$810.59
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.41
|
| Rate for Payer: Blue Shield of California Commercial |
$5.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
| Rate for Payer: Riverside University Health System MISP |
$3.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Other HMO |
$4.65
|
| Rate for Payer: United Healthcare HMO Rider |
$4.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186077660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$4.69
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 0480269506
|
| 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
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 4265811503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186077739
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$4.69
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 6787749160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 4265811503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
| Rate for Payer: Riverside University Health System MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 5022852260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 5022852260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186077760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$4.69
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6945250917
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| 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 |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 6945250917
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 0480269506
|
| 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
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.41
|
| Rate for Payer: Blue Shield of California Commercial |
$5.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
| Rate for Payer: Riverside University Health System MISP |
$3.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Other HMO |
$4.65
|
| Rate for Payer: United Healthcare HMO Rider |
$4.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 6787749160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220536860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077739
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.41
|
| Rate for Payer: Blue Shield of California Commercial |
$5.90
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Central Health Plan Commercial |
$7.44
|
| Rate for Payer: Cigna of CA HMO |
$6.51
|
| Rate for Payer: Cigna of CA PPO |
$6.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.72
|
| Rate for Payer: EPIC Health Plan Senior |
$3.72
|
| Rate for Payer: Galaxy Health WC |
$7.91
|
| Rate for Payer: Global Benefits Group Commercial |
$5.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: Networks By Design Commercial |
$6.04
|
| Rate for Payer: Prime Health Services Commercial |
$7.91
|
| Rate for Payer: Riverside University Health System MISP |
$3.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Other HMO |
$4.65
|
| Rate for Payer: United Healthcare HMO Rider |
$4.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 7220536860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.37
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
