|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-10
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-20
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0527-1632-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 68001-327-00
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 68084-750-95
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| 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 |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 68084-750-95
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 68001-327-00
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 68084-750-25
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.63
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| 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 |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 68084-750-25
|
| Hospital Charge Code |
1710565
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 68001-328-00
|
| Hospital Charge Code |
1711371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 68001-328-00
|
| Hospital Charge Code |
1711371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 60505-2657-1
|
| Hospital Charge Code |
1711371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET [8134]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 60505-2657-1
|
| Hospital Charge Code |
1711371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 51079-575-01
|
| Hospital Charge Code |
1710596
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.62
|
| Rate for Payer: Dignity Health Senior |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| 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 Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Senior |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 51079-575-01
|
| Hospital Charge Code |
1710596
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 51079-575-20
|
| Hospital Charge Code |
1710596
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.62
|
| Rate for Payer: Dignity Health Senior |
$2.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| 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 Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Senior |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 51079-575-20
|
| Hospital Charge Code |
1710596
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
|
|
TRIFLUOPERAZINE 1 MG TABLET [8161]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 51079-572-20
|
| Hospital Charge Code |
1711277
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| 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 |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| 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 |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
TRIFLUOPERAZINE 1 MG TABLET [8161]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 51079-572-20
|
| Hospital Charge Code |
1711277
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| 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 |
$1.00
|
|
|
TRIFLUOPERAZINE 2 MG TABLET [8163]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079-573-01
|
| Hospital Charge Code |
1711281
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
TRIFLUOPERAZINE 2 MG TABLET [8163]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079-573-01
|
| Hospital Charge Code |
1711281
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
TRIFLUOPERAZINE 5 MG TABLET [8164]
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 51079-574-20
|
| Hospital Charge Code |
1710535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.17
|
| Rate for Payer: Dignity Health Senior |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.63
|
| 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 Commercial |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Senior |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Vantage Medical Group Senior |
$2.17
|
|
|
TRIFLUOPERAZINE 5 MG TABLET [8164]
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 51079-574-20
|
| Hospital Charge Code |
1710535
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.75
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.91
|
|
