|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-39
|
| 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 0186-0777-60
|
| 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 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186-0777-60
|
| 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
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 72205-368-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| 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 |
$0.35
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 67877-491-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Senior |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| 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 |
$0.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| 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 |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 72205-368-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 42658-115-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 67877-491-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| 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 |
$0.70
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.72
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$94.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Senior |
$107.10
|
| Rate for Payer: Dignity Health Senior |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$88.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$88.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.40
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$28.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.40
|
| Rate for Payer: TriValley Medical Group Senior |
$50.40
|
| Rate for Payer: TriValley Medical Group Senior |
$28.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Senior |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
TIMOLOL 0.5 % EYE DROPS [15115]
|
Facility
|
OP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$23.32 |
| Rate for Payer: Adventist Health Commercial |
$5.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.57
|
| Rate for Payer: Blue Shield of California Commercial |
$16.73
|
| Rate for Payer: Blue Shield of California EPN |
$13.39
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.32
|
| Rate for Payer: Dignity Health Senior |
$23.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.98
|
| Rate for Payer: Heritage Provider Network Senior |
$16.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.20
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.97
|
| Rate for Payer: TriValley Medical Group Senior |
$10.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.32
|
| Rate for Payer: Vantage Medical Group Senior |
$23.32
|
|
|
TIMOLOL 0.5 % EYE DROPS [15115]
|
Facility
|
IP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$20.57 |
| Rate for Payer: Adventist Health Commercial |
$5.49
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.86
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| 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 Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.97
|
| Rate for Payer: Dignity Health Senior |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Senior |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: Vantage Medical Group Senior |
$1.97
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Senior |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
IP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$20.57 |
| Rate for Payer: Adventist Health Commercial |
$5.49
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.86
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$27.43
|
|
|
Service Code
|
NDC 70069-696-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$23.32 |
| Rate for Payer: Adventist Health Commercial |
$5.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.57
|
| Rate for Payer: Blue Shield of California Commercial |
$16.73
|
| Rate for Payer: Blue Shield of California EPN |
$13.39
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.32
|
| Rate for Payer: Dignity Health Senior |
$23.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.98
|
| Rate for Payer: Heritage Provider Network Senior |
$16.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.20
|
| Rate for Payer: Multiplan Commercial |
$20.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.97
|
| Rate for Payer: TriValley Medical Group Senior |
$10.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.32
|
| Rate for Payer: Vantage Medical Group Senior |
$23.32
|
|
|
TIMOLOL 0.5 % EYE DROPS. [408101]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.98
|
| Rate for Payer: Dignity Health Senior |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Senior |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1.98
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| 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 Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| 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 |
$0.39
|
| 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
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| 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 |
$0.39
|
| 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
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| 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 |
$0.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
