|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$77.40 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.87
|
| Rate for Payer: Heritage Provider Network Senior |
$69.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$55.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Blue Shield of California Commercial |
$62.95
|
| Rate for Payer: Blue Shield of California EPN |
$50.36
|
| Rate for Payer: Cash Price |
$56.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Senior |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.88
|
| Rate for Payer: Heritage Provider Network Senior |
$63.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$49.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.24
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.28
|
| Rate for Payer: TriValley Medical Group Senior |
$41.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| 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 |
$0.53
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| 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 |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 75834-310-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 75834-310-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.79
|
| Rate for Payer: Heritage Provider Network Senior |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$1.98
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.98
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Senior |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.63
|
| Rate for Payer: Heritage Provider Network Senior |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$1.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.06
|
| Rate for Payer: TriValley Medical Group Senior |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| 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 |
$0.91
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Senior |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| 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 |
$0.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Senior |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| 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 |
$0.55
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 75834-311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Senior |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| 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 |
$0.35
|
| 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 |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| 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 |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 75834-312-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$1.35
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.15
|
| Rate for Payer: Dignity Health Senior |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.15
|
| Rate for Payer: Vantage Medical Group Senior |
$1.15
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Senior |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 75834-312-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Senior |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Senior |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.72
|
| Rate for Payer: TriValley Medical Group Senior |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.30
|
| Rate for Payer: Heritage Provider Network Senior |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Senior |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Senior |
$5.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.72
|
| Rate for Payer: TriValley Medical Group Senior |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
