|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| 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: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| 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 |
$0.08
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| 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 |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| 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 |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| 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
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| 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 |
$0.12
|
| 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 |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.09
|
| 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 |
$0.08
|
| 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 |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
IP
|
$6.90
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$5.17 |
| Rate for Payer: Adventist Health Commercial |
$1.38
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.67
|
| Rate for Payer: Heritage Provider Network Senior |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$5.17
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
OP
|
$6.90
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.17
|
| Rate for Payer: Blue Shield of California Commercial |
$4.21
|
| Rate for Payer: Blue Shield of California EPN |
$3.37
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.87
|
| Rate for Payer: Dignity Health Senior |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.83
|
| Rate for Payer: Multiplan Commercial |
$5.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.76
|
| Rate for Payer: TriValley Medical Group Senior |
$2.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.87
|
| Rate for Payer: Vantage Medical Group Senior |
$5.87
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
IP
|
$8.48
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$6.36 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.74
|
| Rate for Payer: Heritage Provider Network Senior |
$5.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$6.36
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
OP
|
$8.48
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.36
|
| Rate for Payer: Blue Shield of California Commercial |
$5.17
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.21
|
| Rate for Payer: Dignity Health Senior |
$7.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Senior |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.94
|
| Rate for Payer: Multiplan Commercial |
$6.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.39
|
| Rate for Payer: TriValley Medical Group Senior |
$3.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.21
|
| Rate for Payer: Vantage Medical Group Senior |
$7.21
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 72578-173-01
|
| 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
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Senior |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 72578-173-01
|
| 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
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.48
|
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.94
|
| Rate for Payer: Dignity Health Senior |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Senior |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.14
|
| Rate for Payer: Heritage Provider Network Senior |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Senior |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
IP
|
$5.12
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.70
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
|
OP
|
$5.12
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$3.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.31
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.07
|
| Rate for Payer: Dignity Health Senior |
$5.07
|
| Rate for Payer: Dignity Health Senior |
$3.16
|
| Rate for Payer: Dignity Health Senior |
$4.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.72
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Senior |
$1.49
|
| Rate for Payer: TriValley Medical Group Senior |
$2.39
|
| Rate for Payer: TriValley Medical Group Senior |
$2.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$3.16
|
| Rate for Payer: Vantage Medical Group Senior |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$4.35
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140729
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 |
$0.02
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140729
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Commercial |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Commercial |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| 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 |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 |
$0.02
|
|
