|
LEVOFLOXACIN 500 MG TABLET [18919]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 65862-537-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
LEVOFLOXACIN 500 MG TABLET [18919]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 13668-083-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.01
|
| Rate for Payer: Blue Shield of California Commercial |
$8.67
|
| Rate for Payer: Blue Shield of California EPN |
$8.67
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 65862-538-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 65862-538-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.26 |
| Max. Negotiated Rate |
$96.39 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$77.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$99.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$108.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$82.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.65
|
| Rate for Payer: Blue Shield of California Commercial |
$10.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.34
|
| Rate for Payer: Blue Shield of California Commercial |
$10.34
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Blue Shield of California EPN |
$10.34
|
| Rate for Payer: Cash Price |
$79.44
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Cash Price |
$62.37
|
| Rate for Payer: Cash Price |
$62.37
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Cash Price |
$79.44
|
| Rate for Payer: Cash Price |
$69.68
|
| Rate for Payer: Cash Price |
$69.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$66.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$122.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$93.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$122.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.69
|
| Rate for Payer: Dignity Health Senior |
$107.69
|
| Rate for Payer: Dignity Health Senior |
$122.77
|
| Rate for Payer: Dignity Health Senior |
$96.39
|
| Rate for Payer: Dignity Health Senior |
$93.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$70.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.87
|
| Rate for Payer: Heritage Provider Network Senior |
$66.87
|
| Rate for Payer: Heritage Provider Network Senior |
$51.01
|
| Rate for Payer: Heritage Provider Network Senior |
$52.50
|
| Rate for Payer: Heritage Provider Network Senior |
$58.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$54.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$68.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$101.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$77.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$88.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$77.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$88.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$101.10
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$57.77
|
| Rate for Payer: TriValley Medical Group Senior |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$44.07
|
| Rate for Payer: TriValley Medical Group Senior |
$50.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$47.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$122.77
|
| Rate for Payer: Vantage Medical Group Senior |
$93.64
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$107.69
|
| Rate for Payer: Vantage Medical Group Senior |
$122.77
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$126.70
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$95.03 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Cash Price |
$62.37
|
| Rate for Payer: Cash Price |
$69.68
|
| Rate for Payer: Cash Price |
$79.44
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$66.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.01
|
| Rate for Payer: Heritage Provider Network Senior |
$66.87
|
| Rate for Payer: Heritage Provider Network Senior |
$51.01
|
| Rate for Payer: Heritage Provider Network Senior |
$52.50
|
| Rate for Payer: Heritage Provider Network Senior |
$58.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.54
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$47.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.48
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 68180-969-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0527-3284-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 72305-100-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 68180-969-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0527-3284-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 72305-100-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
