|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.25
|
| Rate for Payer: BCBS Transplant Transplant |
$4.32
|
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Central Health Plan Commercial |
$5.76
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.40
|
| Rate for Payer: IEHP medi-cal |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: Riverside University Health MISP |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO |
$3.60
|
| Rate for Payer: United Healthcare HMO Rider |
$3.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
IP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Blue Shield of California Commercial |
$5.40
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Central Health Plan Commercial |
$5.76
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
IP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Blue Shield of California Commercial |
$2.80
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Central Health Plan Commercial |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.18
|
| Rate for Payer: Global Benefits Group Commercial |
$2.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$3.18
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
OP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.21
|
| Rate for Payer: BCBS Transplant Transplant |
$2.24
|
| Rate for Payer: Blue Shield of California Commercial |
$2.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.83
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Central Health Plan Commercial |
$2.99
|
| Rate for Payer: Cigna of CA HMO |
$2.62
|
| Rate for Payer: Cigna of CA PPO |
$2.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.50
|
| Rate for Payer: Galaxy Health WC |
$3.18
|
| Rate for Payer: Global Benefits Group Commercial |
$2.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.80
|
| Rate for Payer: IEHP medi-cal |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$3.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.24
|
| Rate for Payer: Riverside University Health MISP |
$1.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO |
$1.87
|
| Rate for Payer: United Healthcare HMO Rider |
$1.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3.18
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
IP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Blue Shield of California Commercial |
$34.18
|
| Rate for Payer: Blue Shield of California EPN |
$24.33
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Central Health Plan Commercial |
$36.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: Galaxy Health WC |
$38.73
|
| Rate for Payer: Global Benefits Group Commercial |
$27.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.11
|
| Rate for Payer: Multiplan Commercial |
$34.18
|
| Rate for Payer: Networks By Design Commercial |
$29.62
|
| Rate for Payer: Prime Health Services Commercial |
$38.73
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
OP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.92
|
| Rate for Payer: BCBS Transplant Transplant |
$27.34
|
| Rate for Payer: Blue Shield of California Commercial |
$28.66
|
| Rate for Payer: Blue Shield of California EPN |
$22.28
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Central Health Plan Commercial |
$36.46
|
| Rate for Payer: Cigna of CA HMO |
$29.16
|
| Rate for Payer: Cigna of CA PPO |
$33.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.23
|
| Rate for Payer: Galaxy Health WC |
$38.73
|
| Rate for Payer: Global Benefits Group Commercial |
$27.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$41.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.18
|
| Rate for Payer: IEHP medi-cal |
$15.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.11
|
| Rate for Payer: Multiplan Commercial |
$34.18
|
| Rate for Payer: Networks By Design Commercial |
$29.62
|
| Rate for Payer: Prime Health Services Commercial |
$38.73
|
| Rate for Payer: Riverside University Health MISP |
$18.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.78
|
| Rate for Payer: United Healthcare All Other HMO |
$22.78
|
| Rate for Payer: United Healthcare HMO Rider |
$22.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.73
|
| Rate for Payer: Vantage Medical Group Senior |
$38.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: BCBS Transplant Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.96
|
| Rate for Payer: IEHP medi-cal |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: Riverside University Health MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: BCBS Transplant Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.96
|
| Rate for Payer: IEHP medi-cal |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: Riverside University Health MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.33
|
| Rate for Payer: BCBS Transplant Transplant |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.96
|
| Rate for Payer: IEHP medi-cal |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: Riverside University Health MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| 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: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
OP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$54.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.15
|
| Rate for Payer: BCBS Transplant Transplant |
$56.90
|
| Rate for Payer: Blue Shield of California Commercial |
$58.60
|
| Rate for Payer: Blue Shield of California EPN |
$46.09
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$71.12
|
| Rate for Payer: IEHP medi-cal |
$33.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: Riverside University Health MISP |
$37.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$47.42
|
| Rate for Payer: United Healthcare All Other HMO |
$47.42
|
| Rate for Payer: United Healthcare HMO Rider |
$47.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$47.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
IP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: Blue Shield of California Commercial |
$71.12
|
| Rate for Payer: Blue Shield of California EPN |
$50.64
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: 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: 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: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: 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: 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: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
IP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.05
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Central Health Plan Commercial |
$4.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$4.28
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
OP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.37
|
| Rate for Payer: BCBS Transplant Transplant |
$3.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Central Health Plan Commercial |
$4.57
|
| Rate for Payer: Cigna of CA HMO |
$4.00
|
| Rate for Payer: Cigna of CA PPO |
$4.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.28
|
| Rate for Payer: Galaxy Health WC |
$4.85
|
| Rate for Payer: Global Benefits Group Commercial |
$3.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.28
|
| Rate for Payer: IEHP medi-cal |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$4.28
|
| Rate for Payer: Networks By Design Commercial |
$3.71
|
| Rate for Payer: Prime Health Services Commercial |
$4.85
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: Riverside University Health MISP |
$2.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare HMO Rider |
$2.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.85
|
| Rate for Payer: Vantage Medical Group Senior |
$4.85
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
OP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.15
|
| Rate for Payer: BCBS Transplant Transplant |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.43
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Central Health Plan Commercial |
$5.62
|
| Rate for Payer: Cigna of CA HMO |
$4.91
|
| Rate for Payer: Cigna of CA PPO |
$4.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$5.97
|
| Rate for Payer: Global Benefits Group Commercial |
$4.21
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.26
|
| Rate for Payer: IEHP medi-cal |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Networks By Design Commercial |
$4.56
|
| Rate for Payer: Prime Health Services Commercial |
$5.97
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.21
|
| Rate for Payer: Riverside University Health MISP |
$2.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.51
|
| Rate for Payer: United Healthcare All Other HMO |
$3.51
|
| Rate for Payer: United Healthcare HMO Rider |
$3.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
