|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
IP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.26
|
| Rate for Payer: Blue Shield of California EPN |
$3.75
|
| Rate for Payer: Cash Price |
$3.16
|
| 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: EPIC Health Plan Commercial |
$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: 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
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Central Health Plan Commercial |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.09
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Central Health Plan Commercial |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: BCBS Transplant Transplant |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Central Health Plan Commercial |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.09
|
| Rate for Payer: IEHP medi-cal |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: Riverside University Health MISP |
$1.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.06
|
| Rate for Payer: United Healthcare HMO Rider |
$2.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.43
|
| Rate for Payer: BCBS Transplant Transplant |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Central Health Plan Commercial |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$2.88
|
| Rate for Payer: Cigna of CA PPO |
$2.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.65
|
| Rate for Payer: Galaxy Health WC |
$3.50
|
| Rate for Payer: Global Benefits Group Commercial |
$2.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.09
|
| Rate for Payer: IEHP medi-cal |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Networks By Design Commercial |
$2.68
|
| Rate for Payer: Prime Health Services Commercial |
$3.50
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: Riverside University Health MISP |
$1.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.06
|
| Rate for Payer: United Healthcare All Other HMO |
$2.06
|
| Rate for Payer: United Healthcare HMO Rider |
$2.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
IP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$2.48
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Central Health Plan Commercial |
$3.71
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Prime Health Services Commercial |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
OP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.74
|
| Rate for Payer: BCBS Transplant Transplant |
$2.78
|
| Rate for Payer: Blue Shield of California Commercial |
$2.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.27
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Central Health Plan Commercial |
$3.71
|
| Rate for Payer: Cigna of CA HMO |
$3.25
|
| Rate for Payer: Cigna of CA PPO |
$3.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.48
|
| Rate for Payer: IEHP medi-cal |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: Networks By Design Commercial |
$3.02
|
| Rate for Payer: Prime Health Services Commercial |
$3.94
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.78
|
| Rate for Payer: Riverside University Health MISP |
$1.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.32
|
| Rate for Payer: United Healthcare All Other HMO |
$2.32
|
| Rate for Payer: United Healthcare HMO Rider |
$2.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
OP
|
$1.61
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
ERX110533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: BCBS Transplant Transplant |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.21
|
| Rate for Payer: IEHP medi-cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: Riverside University Health MISP |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
IP
|
$1.61
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
ERX110533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 2055502700
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 2055502700
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Central Health Plan Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.01
|
| Rate for Payer: IEHP medi-cal |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$0.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| 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 |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 8068100300
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| 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: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068100300
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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: 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: 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/ML INJECTION SOLUTION [7876]
|
Facility
IP
|
$5.12
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
1757658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$4.48
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Central Health Plan Commercial |
$4.78
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA HMO |
$4.18
|
| Rate for Payer: Cigna of CA PPO |
$4.18
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$5.07
|
| Rate for Payer: Galaxy Health WC |
$4.35
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Global Benefits Group Commercial |
$3.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Prime Health Services Commercial |
$5.07
|
| Rate for Payer: Prime Health Services Commercial |
$4.35
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
OP
|
$5.97
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
1757658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.83
|
| Rate for Payer: BCBS Transplant Transplant |
$3.07
|
| Rate for Payer: BCBS Transplant Transplant |
$3.58
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$5.15
|
| Rate for Payer: Blue Shield of California EPN |
$5.15
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Central Health Plan Commercial |
$4.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.10
|
| Rate for Payer: Cigna of CA HMO |
$4.18
|
| Rate for Payer: Cigna of CA HMO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$3.58
|
| Rate for Payer: Cigna of CA PPO |
$4.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.39
|
| Rate for Payer: Galaxy Health WC |
$5.07
|
| Rate for Payer: Galaxy Health WC |
$4.35
|
| Rate for Payer: Global Benefits Group Commercial |
$3.58
|
| Rate for Payer: Global Benefits Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.48
|
| Rate for Payer: IEHP medi-cal |
$1.94
|
| Rate for Payer: IEHP medi-cal |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Networks By Design Commercial |
$2.98
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$4.35
|
| Rate for Payer: Prime Health Services Commercial |
$5.07
|
| Rate for Payer: Riverside University Health MISP |
$2.05
|
| Rate for Payer: Riverside University Health MISP |
$2.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.98
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.98
|
| Rate for Payer: United Healthcare HMO Rider |
$2.98
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$4.35
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
1711135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| 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: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
1711135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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: 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: 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
|
|
