|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 55111-180-15
|
| 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: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| 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 |
$0.09
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| 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 |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| 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 |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 29300-169-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| 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 Commercial |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 29300-169-15
|
| 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: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| 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 |
$0.09
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.63
|
|
|
Service Code
|
NDC 0904-6418-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| 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 |
$0.31
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| 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 |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.44
|
| 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 |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 60505-0252-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 55111-180-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| 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 Commercial |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 60505-0252-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
IP
|
$18.25
|
|
|
Service Code
|
NDC 0574-4031-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Adventist Health Commercial |
$3.65
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.36
|
| Rate for Payer: Heritage Provider Network Senior |
$12.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.56
|
| Rate for Payer: Multiplan Commercial |
$13.69
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
OP
|
$18.25
|
|
|
Service Code
|
NDC 0574-4031-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$15.51 |
| Rate for Payer: Adventist Health Commercial |
$3.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.69
|
| Rate for Payer: Blue Shield of California Commercial |
$11.13
|
| Rate for Payer: Blue Shield of California EPN |
$8.91
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.51
|
| Rate for Payer: Dignity Health Senior |
$15.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.30
|
| Rate for Payer: Heritage Provider Network Senior |
$11.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.78
|
| Rate for Payer: Multiplan Commercial |
$13.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Senior |
$7.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.51
|
| Rate for Payer: Vantage Medical Group Senior |
$15.51
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
IP
|
$18.21
|
|
|
Service Code
|
NDC 0574-4031-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$13.66 |
| Rate for Payer: Adventist Health Commercial |
$3.64
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.33
|
| Rate for Payer: Heritage Provider Network Senior |
$12.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$13.66
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
OP
|
$18.21
|
|
|
Service Code
|
NDC 0574-4031-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Adventist Health Commercial |
$3.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.66
|
| Rate for Payer: Blue Shield of California Commercial |
$11.11
|
| Rate for Payer: Blue Shield of California EPN |
$8.89
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.48
|
| Rate for Payer: Dignity Health Senior |
$15.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.27
|
| Rate for Payer: Heritage Provider Network Senior |
$11.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$13.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Senior |
$7.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.48
|
| Rate for Payer: Vantage Medical Group Senior |
$15.48
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
IP
|
$24.34
|
|
|
Service Code
|
NDC 24208-295-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Adventist Health Commercial |
$4.87
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.48
|
| Rate for Payer: Heritage Provider Network Senior |
$16.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.08
|
| Rate for Payer: Multiplan Commercial |
$18.25
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
OP
|
$24.34
|
|
|
Service Code
|
NDC 24208-295-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Adventist Health Commercial |
$4.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.25
|
| Rate for Payer: Blue Shield of California Commercial |
$14.85
|
| Rate for Payer: Blue Shield of California EPN |
$11.88
|
| Rate for Payer: Cash Price |
$13.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.69
|
| Rate for Payer: Dignity Health Senior |
$20.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.07
|
| Rate for Payer: Heritage Provider Network Senior |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.04
|
| Rate for Payer: Multiplan Commercial |
$18.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.74
|
| Rate for Payer: TriValley Medical Group Senior |
$9.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.69
|
| Rate for Payer: Vantage Medical Group Senior |
$20.69
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [7995]
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
NDC 62332-518-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Senior |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [7995]
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
NDC 62332-518-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.16
|
| Rate for Payer: Dignity Health Senior |
$3.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Senior |
$1.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.16
|
| Rate for Payer: Vantage Medical Group Senior |
$3.16
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [7995]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 70069-131-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [7995]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 70069-131-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| 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 |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
NDC 61314-643-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Senior |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 24208-290-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.40
|
| Rate for Payer: Dignity Health Senior |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Vantage Medical Group Senior |
$2.40
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 24208-290-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
NDC 61314-643-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Adventist Health Commercial |
$0.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.27
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.16
|
| Rate for Payer: Dignity Health Senior |
$3.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Senior |
$1.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.16
|
| Rate for Payer: Vantage Medical Group Senior |
$3.16
|
|
