|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140729
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0904719106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| 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 |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: InnovAge PACE Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA 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 |
$0.15
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 1184573105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 1184573105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| 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 |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: InnovAge PACE Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA 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 |
$0.15
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.03
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7733393425
|
| 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 |
$0.11
|
| 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: 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: InnovAge PACE Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: InnovAge PACE Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 7733393425
|
| 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 |
$0.11
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| 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
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: InnovAge PACE Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.43
|
| Rate for Payer: InnovAge PACE Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Riverside University Health System MISP |
$2.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Central Health Plan Commercial |
$4.82
|
| Rate for Payer: Cigna of CA HMO |
$4.22
|
| Rate for Payer: Cigna of CA PPO |
$4.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.41
|
| Rate for Payer: EPIC Health Plan Senior |
$2.41
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Senior |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: InnovAge PACE Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Riverside University Health System MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$810.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$695.70
|
| Rate for Payer: Blue Shield of California EPN |
$453.60
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Central Health Plan Commercial |
$720.00
|
| Rate for Payer: Cigna of CA HMO |
$630.00
|
| Rate for Payer: Cigna of CA PPO |
$630.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$360.00
|
| Rate for Payer: EPIC Health Plan Senior |
$360.00
|
| Rate for Payer: Galaxy Health WC |
$765.00
|
| Rate for Payer: Global Benefits Group Commercial |
$540.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$810.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$600.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$342.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$557.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: Networks By Design Commercial |
$450.00
|
| Rate for Payer: Prime Health Services Commercial |
$765.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.77
|
| Rate for Payer: United Healthcare All Other HMO |
$328.77
|
| Rate for Payer: United Healthcare HMO Rider |
$321.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.75
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$810.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$12.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$546.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.15
|
| Rate for Payer: Blue Shield of California Commercial |
$549.90
|
| Rate for Payer: Blue Shield of California EPN |
$359.10
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Central Health Plan Commercial |
$720.00
|
| Rate for Payer: Cigna of CA HMO |
$630.00
|
| Rate for Payer: Cigna of CA PPO |
$630.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.52
|
| Rate for Payer: EPIC Health Plan Senior |
$12.24
|
| Rate for Payer: Galaxy Health WC |
$765.00
|
| Rate for Payer: Global Benefits Group Commercial |
$540.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$810.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$20.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.24
|
| Rate for Payer: InnovAge PACE Commercial |
$18.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$600.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$342.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.40
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: Networks By Design Commercial |
$450.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$12.24
|
| Rate for Payer: Prime Health Services Commercial |
$765.00
|
| Rate for Payer: Prime Health Services Medicare |
$12.97
|
| Rate for Payer: Riverside University Health System MISP |
$13.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$540.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$540.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$337.77
|
| Rate for Payer: United Healthcare All Other HMO |
$328.77
|
| Rate for Payer: United Healthcare HMO Rider |
$321.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$294.75
|
| Rate for Payer: Upland Medical Group Pediatric |
$12.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.46
|
| Rate for Payer: Vantage Medical Group Senior |
$12.24
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
IP
|
$85.86
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.17 |
| Max. Negotiated Rate |
$77.27 |
| Rate for Payer: Adventist Health Commercial |
$17.17
|
| Rate for Payer: Blue Shield of California Commercial |
$66.37
|
| Rate for Payer: Blue Shield of California EPN |
$43.27
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Central Health Plan Commercial |
$68.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.34
|
| Rate for Payer: EPIC Health Plan Senior |
$34.34
|
| Rate for Payer: Galaxy Health WC |
$72.98
|
| Rate for Payer: Global Benefits Group Commercial |
$51.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$77.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$57.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.17
|
| Rate for Payer: Multiplan Commercial |
$64.39
|
| Rate for Payer: Networks By Design Commercial |
$55.81
|
| Rate for Payer: Prime Health Services Commercial |
$72.98
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
OP
|
$85.86
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.17 |
| Max. Negotiated Rate |
$77.27 |
| Rate for Payer: Adventist Health Commercial |
$17.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$52.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$41.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.43
|
| Rate for Payer: Blue Shield of California Commercial |
$52.46
|
| Rate for Payer: Blue Shield of California EPN |
$34.26
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Central Health Plan Commercial |
$68.69
|
| Rate for Payer: Cigna of CA HMO |
$54.95
|
| Rate for Payer: Cigna of CA PPO |
$63.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$72.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.34
|
| Rate for Payer: EPIC Health Plan Senior |
$34.34
|
| Rate for Payer: Galaxy Health WC |
$72.98
|
| Rate for Payer: Global Benefits Group Commercial |
$51.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$77.27
|
| Rate for Payer: InnovAge PACE Commercial |
$42.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$57.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.10
|
| Rate for Payer: Multiplan Commercial |
$64.39
|
| Rate for Payer: Networks By Design Commercial |
$55.81
|
| Rate for Payer: Prime Health Services Commercial |
$72.98
|
| Rate for Payer: Riverside University Health System MISP |
$34.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$51.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$51.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.93
|
| Rate for Payer: United Healthcare All Other HMO |
$42.93
|
| Rate for Payer: United Healthcare HMO Rider |
$42.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.98
|
| Rate for Payer: Vantage Medical Group Senior |
$72.98
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
IP
|
$87.49
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$78.74 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Blue Shield of California Commercial |
$67.63
|
| Rate for Payer: Blue Shield of California EPN |
$44.09
|
| Rate for Payer: Cash Price |
$48.12
|
| Rate for Payer: Central Health Plan Commercial |
$69.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.00
|
| Rate for Payer: EPIC Health Plan Senior |
$35.00
|
| Rate for Payer: Galaxy Health WC |
$74.37
|
| Rate for Payer: Global Benefits Group Commercial |
$52.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$78.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$54.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Multiplan Commercial |
$65.62
|
| Rate for Payer: Networks By Design Commercial |
$56.87
|
| Rate for Payer: Prime Health Services Commercial |
$74.37
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
OP
|
$87.49
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$78.74 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$53.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$42.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.38
|
| Rate for Payer: Blue Shield of California Commercial |
$53.46
|
| Rate for Payer: Blue Shield of California EPN |
$34.91
|
| Rate for Payer: Cash Price |
$48.12
|
| Rate for Payer: Central Health Plan Commercial |
$69.99
|
| Rate for Payer: Cigna of CA HMO |
$55.99
|
| Rate for Payer: Cigna of CA PPO |
$64.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$74.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.00
|
| Rate for Payer: EPIC Health Plan Senior |
$35.00
|
| Rate for Payer: Galaxy Health WC |
$74.37
|
| Rate for Payer: Global Benefits Group Commercial |
$52.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$78.74
|
| Rate for Payer: InnovAge PACE Commercial |
$43.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$54.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$61.24
|
| Rate for Payer: Multiplan Commercial |
$65.62
|
| Rate for Payer: Networks By Design Commercial |
$56.87
|
| Rate for Payer: Prime Health Services Commercial |
$74.37
|
| Rate for Payer: Riverside University Health System MISP |
$35.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$52.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$52.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.74
|
| Rate for Payer: United Healthcare All Other HMO |
$43.74
|
| Rate for Payer: United Healthcare HMO Rider |
$43.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$43.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.37
|
| Rate for Payer: Vantage Medical Group Senior |
$74.37
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$92.88 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$62.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$49.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.61
|
| Rate for Payer: Blue Shield of California Commercial |
$63.06
|
| Rate for Payer: Blue Shield of California EPN |
$41.18
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Central Health Plan Commercial |
$82.56
|
| Rate for Payer: Cigna of CA HMO |
$66.05
|
| Rate for Payer: Cigna of CA PPO |
$76.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$92.88
|
| Rate for Payer: InnovAge PACE Commercial |
$51.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.24
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
| Rate for Payer: Riverside University Health System MISP |
$41.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$51.60
|
| Rate for Payer: United Healthcare All Other HMO |
$51.60
|
| Rate for Payer: United Healthcare HMO Rider |
$51.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$92.88 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Blue Shield of California Commercial |
$79.77
|
| Rate for Payer: Blue Shield of California EPN |
$52.01
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Central Health Plan Commercial |
$82.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.28
|
| Rate for Payer: EPIC Health Plan Senior |
$41.28
|
| Rate for Payer: Galaxy Health WC |
$87.72
|
| Rate for Payer: Global Benefits Group Commercial |
$61.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$92.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.64
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
| Rate for Payer: Networks By Design Commercial |
$67.08
|
| Rate for Payer: Prime Health Services Commercial |
$87.72
|
|
