|
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 |
$44.47 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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 |
$44.47
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Foundation Hospitals 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
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 0904635361
|
| 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: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| 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 Foundation Hospitals 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
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 6586253820
|
| 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: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.39
|
| 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 Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0904635361
|
| 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 Non-Gatekeeper |
$0.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| 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 |
$0.24
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 6586253820
|
| 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 Non-Gatekeeper |
$0.54
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| 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 |
$0.39
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0555902079
|
| 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: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| 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 Foundation Hospitals 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
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0555902058
|
| 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: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| 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 Foundation Hospitals 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 0555902058
|
| 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 Non-Gatekeeper |
$0.15
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| 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 |
$0.11
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0555902079
|
| 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 Non-Gatekeeper |
$0.15
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| 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 |
$0.11
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
IP
|
$1,526.93
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$276.37 |
| Max. Negotiated Rate |
$1,145.20 |
| Rate for Payer: Adventist Health Commercial |
$305.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$983.34
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$702.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$824.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$706.97
|
| Rate for Payer: Heritage Provider Network Senior |
$706.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$276.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.73
|
| Rate for Payer: Multiplan Commercial |
$1,145.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$551.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$505.57
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
OP
|
$1,526.93
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$276.37 |
| Max. Negotiated Rate |
$2,080.77 |
| Rate for Payer: Adventist Health Commercial |
$305.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$943.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$839.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,145.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,080.77
|
| Rate for Payer: Blue Shield of California Commercial |
$1,179.93
|
| Rate for Payer: Blue Shield of California EPN |
$1,179.93
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Cash Price |
$687.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$702.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,297.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,297.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$977.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$706.97
|
| Rate for Payer: Heritage Provider Network Senior |
$706.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$728.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$276.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$381.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,068.85
|
| Rate for Payer: Multiplan Commercial |
$1,145.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$610.77
|
| Rate for Payer: TriValley Medical Group Senior |
$610.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$551.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$505.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,297.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,297.89
|
| Rate for Payer: Vantage Medical Group Senior |
$1,297.89
|
|
|
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
IP
|
$1,173.98
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.49 |
| Max. Negotiated Rate |
$880.49 |
| Rate for Payer: Adventist Health Commercial |
$234.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$756.04
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$540.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$633.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$543.55
|
| Rate for Payer: Heritage Provider Network Senior |
$543.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$212.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$293.50
|
| Rate for Payer: Multiplan Commercial |
$880.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$424.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$388.70
|
|
|
LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
OP
|
$1,173.98
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.49 |
| Max. Negotiated Rate |
$1,515.13 |
| Rate for Payer: Adventist Health Commercial |
$234.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$725.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$997.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$645.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$880.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,515.13
|
| Rate for Payer: Blue Shield of California Commercial |
$905.11
|
| Rate for Payer: Blue Shield of California EPN |
$905.11
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Cash Price |
$528.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$540.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$997.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$997.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$997.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$751.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$543.55
|
| Rate for Payer: Heritage Provider Network Senior |
$543.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$559.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$212.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$293.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$821.79
|
| Rate for Payer: Multiplan Commercial |
$880.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$469.59
|
| Rate for Payer: TriValley Medical Group Senior |
$469.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$424.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$388.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$997.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$997.88
|
| Rate for Payer: Vantage Medical Group Senior |
$997.88
|
|
|
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 |
$22.68
|
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.01
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$64.99
|
| 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: EPIC Health Plan Commercial |
$61.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.49
|
| 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 Commercial |
$58.66
|
| Rate for Payer: Heritage Provider Network Senior |
$58.66
|
| 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 |
$66.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.93
|
| 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 |
$28.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.54
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.97
|
| 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 |
$52.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$47.82
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$126.70
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$107.69 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Adventist Health Commercial |
$28.89
|
| Rate for Payer: Adventist Health Commercial |
$22.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$89.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.69
|
| 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 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 Medi-Cal |
$69.69
|
| 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: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.61
|
| 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 |
$64.99
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cash Price |
$64.99
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$49.58
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cash Price |
$51.03
|
| 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: Cigna of CA HMO/PPO |
$58.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$122.77
|
| 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 |
$107.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$107.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$122.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$93.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.44
|
| 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 |
$81.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.01
|
| Rate for Payer: Heritage Provider Network Senior |
$58.66
|
| Rate for Payer: Heritage Provider Network Senior |
$52.50
|
| Rate for Payer: Heritage Provider Network Senior |
$66.87
|
| Rate for Payer: Heritage Provider Network Senior |
$51.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$60.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$68.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$52.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.54
|
| 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 |
$28.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$88.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$77.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.10
|
| Rate for Payer: Multiplan Commercial |
$108.32
|
| Rate for Payer: Multiplan Commercial |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: Multiplan Commercial |
$82.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$44.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$57.77
|
| Rate for Payer: TriValley Medical Group Senior |
$50.68
|
| Rate for Payer: TriValley Medical Group Senior |
$44.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.18
|
| 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 |
$45.78
|
| 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: United Healthcare Navigate/Select/Select+ |
$47.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$122.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.69
|
| 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 |
$122.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$93.64
|
| Rate for Payer: Vantage Medical Group Senior |
$107.69
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$122.77
|
| Rate for Payer: Vantage Medical Group Senior |
$93.64
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 6068749701
|
| 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 Non-Gatekeeper |
$0.44
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| 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 |
$0.32
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 6068749711
|
| 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 Non-Gatekeeper |
$0.44
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| 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 |
$0.32
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.13
|
|
|
Service Code
|
NDC 0527328446
|
| 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: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Foundation Hospitals 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
|
$0.72
|
|
|
Service Code
|
NDC 6068749711
|
| 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: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 Foundation Hospitals 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
|
$0.09
|
|
|
Service Code
|
NDC 1672945115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 7230510030
|
| 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: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 6818096909
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 7230510030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.17
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 6923818341
|
| 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 Non-Gatekeeper |
$0.21
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| 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 |
$0.15
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
