|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
OP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.34
|
| Rate for Payer: Blue Shield of California Commercial |
$58.89
|
| Rate for Payer: Blue Shield of California EPN |
$55.67
|
| 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 Senior |
$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: IEHP Medi-Cal |
$41.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$45.71
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$34.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.68
|
| 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
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
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 |
$0.07
|
| 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 Permanente of CA 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 ELIXIR [7820]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0820-16
|
| Hospital Charge Code |
1715472
|
|
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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
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 |
$0.13
|
| 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 Permanente of CA 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 27808-033-01
|
| Hospital Charge Code |
NDG7821
|
|
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 Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION [7821]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
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 |
$0.13
|
| 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 Permanente of CA 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 54838-556-80
|
| Hospital Charge Code |
NDG7821
|
|
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 Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| 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
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.28
|
| Rate for Payer: Blue Shield of California Commercial |
$3.55
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.85
|
| Rate for Payer: Dignity Health Senior |
$4.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.53
|
| Rate for Payer: Heritage Provider Network Senior |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.85
|
| Rate for Payer: Vantage Medical Group Senior |
$4.85
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR [27419]
|
Facility
IP
|
$5.71
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
ERX27419
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.92
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.28
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
OP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4.36
|
| Rate for Payer: Blue Shield of California EPN |
$4.12
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.97
|
| Rate for Payer: Dignity Health Senior |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
|
THEOPHYLLINE ER 300 MG CAPSULE,EXTENDED RELEASE 24 HR [27421]
|
Facility
IP
|
$7.02
|
|
|
Service Code
|
NDC 52244-300-10
|
| Hospital Charge Code |
ERX27421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.75
|
| Rate for Payer: Heritage Provider Network Senior |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.76
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.50
|
| Rate for Payer: Dignity Health Senior |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.83
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Senior |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
OP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.42
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.50
|
| Rate for Payer: Dignity Health Senior |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.50
|
| Rate for Payer: Vantage Medical Group Senior |
$3.50
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR [12098]
|
Facility
IP
|
$4.12
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
1710671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Adventist Health Commercial |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.83
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Senior |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$3.09
|
|
|
THEOPHYLLINE ER 400 MG CAPSULE,EXTENDED RELEASE 24 HR [31783]
|
Facility
IP
|
$4.64
|
|
|
Service Code
|
NDC 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
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 |
$3.19
|
| 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 Permanente of CA 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 50474-400-01
|
| Hospital Charge Code |
1712630
|
|
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 Gatekeeper |
$2.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.48
|
| Rate for Payer: Blue Shield of California Commercial |
$2.88
|
| Rate for Payer: Blue Shield of California EPN |
$2.72
|
| 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 Senior |
$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 Permanente of CA Commercial |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
| 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
IP
|
$1.61
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
ERX110533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]
|
Facility
OP
|
$1.61
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
ERX110533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Senior |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 2055502700
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 2055502700
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068100300
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 8068100300
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET. [4087857]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
1711076
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
