|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$4.07
|
|
|
Service Code
|
NDC 65162-914-46
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.39
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.46
|
| Rate for Payer: Dignity Health Senior |
$3.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Senior |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Vantage Medical Group Senior |
$3.46
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-84
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$13.13 |
| Rate for Payer: Adventist Health Commercial |
$3.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.59
|
| Rate for Payer: Blue Shield of California Commercial |
$9.59
|
| Rate for Payer: Blue Shield of California EPN |
$9.07
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.13
|
| Rate for Payer: Dignity Health Senior |
$13.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.56
|
| Rate for Payer: Heritage Provider Network Senior |
$9.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$11.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.18
|
| Rate for Payer: TriValley Medical Group Senior |
$6.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.13
|
| Rate for Payer: Vantage Medical Group Senior |
$13.13
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$10.82
|
|
|
Service Code
|
NDC 17478-340-38
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Adventist Health Commercial |
$2.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.12
|
| Rate for Payer: Blue Shield of California Commercial |
$6.72
|
| Rate for Payer: Blue Shield of California EPN |
$6.35
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.20
|
| Rate for Payer: Dignity Health Senior |
$9.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.70
|
| Rate for Payer: Heritage Provider Network Senior |
$6.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$8.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.33
|
| Rate for Payer: TriValley Medical Group Senior |
$4.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.20
|
| Rate for Payer: Vantage Medical Group Senior |
$9.20
|
|
|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 43598-605-04
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.40
|
| Rate for Payer: Dignity Health Senior |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Senior |
$1.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Vantage Medical Group Senior |
$2.40
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Senior |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| 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: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
OP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Adventist Health Commercial |
$16.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.62
|
| Rate for Payer: Blue Shield of California Commercial |
$51.02
|
| Rate for Payer: Blue Shield of California EPN |
$48.23
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.84
|
| Rate for Payer: Dignity Health Senior |
$69.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.86
|
| Rate for Payer: Heritage Provider Network Senior |
$50.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$61.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.86
|
| Rate for Payer: TriValley Medical Group Senior |
$32.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.84
|
| Rate for Payer: Vantage Medical Group Senior |
$69.84
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
IP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$61.62 |
| Rate for Payer: Adventist Health Commercial |
$16.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.44
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.62
|
| Rate for Payer: Heritage Provider Network Senior |
$55.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$61.62
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
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 |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| 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: 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: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
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: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| 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
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| 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 Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| 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: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| 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 |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.70
|
| Rate for Payer: Dignity Health Senior |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Senior |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.18
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| 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 Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
