|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 0456046401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.78
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.88
|
| Rate for Payer: Heritage Provider Network Senior |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 0456046401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 0456045801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Vantage Medical Group Senior |
$1.08
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 4219232901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Vantage Medical Group Senior |
$0.70
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.73
|
|
|
Service Code
|
NDC 7583431101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.33
|
| 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 |
$0.55
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 7583431101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.35
|
| 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 |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 4219232901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 0456045801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 7583431201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 0456045901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Senior |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 7583431201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 4219233001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 4219233030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 4219233001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 4219233030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 0456045901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Senior |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.21
|
| Rate for Payer: Vantage Medical Group Senior |
$1.21
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
|
OP
|
$2,475.08
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$447.99 |
| Max. Negotiated Rate |
$2,892.60 |
| Rate for Payer: Adventist Health Commercial |
$495.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,529.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,374.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,374.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,205.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,016.79
|
| Rate for Payer: Blue Shield of California EPN |
$2,016.79
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,138.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,374.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,374.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,584.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,158.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,145.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1,145.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,158.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,180.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$447.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,482.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$618.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,892.60
|
| Rate for Payer: Multiplan Commercial |
$1,856.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$990.03
|
| Rate for Payer: TriValley Medical Group Senior |
$990.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$894.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$819.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,698.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,374.53
|
| Rate for Payer: Vantage Medical Group Senior |
$2,374.53
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
|
IP
|
$2,475.08
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$447.99 |
| Max. Negotiated Rate |
$1,856.31 |
| Rate for Payer: Adventist Health Commercial |
$495.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,593.95
|
| Rate for Payer: Cash Price |
$1,113.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,138.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,336.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,145.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1,145.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$447.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$618.77
|
| Rate for Payer: Multiplan Commercial |
$1,856.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$894.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$819.50
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186077660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.99
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.30
|
| Rate for Payer: Heritage Provider Network Senior |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.65
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Senior |
$5.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.72
|
| Rate for Payer: TriValley Medical Group Senior |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 0186077760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.99
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.30
|
| Rate for Payer: Heritage Provider Network Senior |
$6.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.65
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Senior |
$5.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.72
|
| Rate for Payer: TriValley Medical Group Senior |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 4265811503
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 0186077739
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Adventist Health Commercial |
$1.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.65
|
| Rate for Payer: Blue Shield of California Commercial |
$5.67
|
| Rate for Payer: Blue Shield of California EPN |
$4.54
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.76
|
| Rate for Payer: Heritage Provider Network Senior |
$5.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$6.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.72
|
| Rate for Payer: TriValley Medical Group Senior |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.91
|
| Rate for Payer: Vantage Medical Group Senior |
$7.91
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 7220536860
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
