|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 6021915231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$71.12 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.07
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.20
|
| Rate for Payer: Heritage Provider Network Senior |
$64.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.71
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.40
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.17
|
| Rate for Payer: Blue Shield of California Commercial |
$57.85
|
| Rate for Payer: Blue Shield of California EPN |
$46.28
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.70
|
| Rate for Payer: Heritage Provider Network Senior |
$58.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 2780803301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 2780803301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 5224420010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.39
|
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Senior |
$4.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.98
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.84
|
| Rate for Payer: TriValley Medical Group Senior |
$2.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6.04
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 5224420010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.58
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.81
|
| Rate for Payer: Heritage Provider Network Senior |
$4.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$5.33
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
OP
|
$8.74
|
|
|
Service Code
|
NDC 5224430010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.37
|
| Rate for Payer: Blue Shield of California Commercial |
$5.33
|
| Rate for Payer: Blue Shield of California EPN |
$4.27
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.41
|
| Rate for Payer: Heritage Provider Network Senior |
$5.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.50
|
| Rate for Payer: TriValley Medical Group Senior |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.43
|
| Rate for Payer: Vantage Medical Group Senior |
$7.43
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
|
IP
|
$8.74
|
|
|
Service Code
|
NDC 5224430010
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.63
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.92
|
| Rate for Payer: Heritage Provider Network Senior |
$5.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6846272101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6233202531
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6233202531
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 7257817301
|
| 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 Non-Gatekeeper |
$0.44
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| 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 |
$0.32
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 7257817301
|
| 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: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6846272101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 5047440001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.99
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.14
|
| Rate for Payer: Heritage Provider Network Senior |
$3.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 5047440001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.32
|
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Senior |
$2.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.94
|
| Rate for Payer: Vantage Medical Group Senior |
$3.94
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 6846238001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
