|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
IP
|
$5.12
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
1757658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]
|
Facility
OP
|
$5.97
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
1757658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$6.03 |
| Rate for Payer: Adventist Health Commercial |
$1.19
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$4.31
|
| Rate for Payer: Blue Shield of California Commercial |
$4.31
|
| Rate for Payer: Blue Shield of California EPN |
$4.31
|
| Rate for Payer: Blue Shield of California EPN |
$4.31
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.07
|
| Rate for Payer: Dignity Health Senior |
$5.07
|
| Rate for Payer: Dignity Health Senior |
$4.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
| Rate for Payer: Multiplan Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.07
|
| Rate for Payer: Vantage Medical Group Senior |
$4.35
|
| Rate for Payer: Vantage Medical Group Senior |
$5.07
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
1711135
|
|
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
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
1711135
|
|
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 |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 8068109800
|
| Hospital Charge Code |
1711135
|
|
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
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 4098521151
|
| Hospital Charge Code |
1711135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 8770140729
|
| Hospital Charge Code |
1711135
|
|
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 |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 8770140729
|
| Hospital Charge Code |
1711135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 1184573105
|
| Hospital Charge Code |
ERX8650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| 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 |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| 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 |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 1184573105
|
| Hospital Charge Code |
ERX8650
|
|
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 |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| Hospital Charge Code |
ERX4081453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 8068109700
|
| Hospital Charge Code |
ERX4081453
|
|
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 |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 5026885111
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]
|
Facility
OP
|
$0.23
|
|
|
Service Code
|
NDC 5026885115
|
| Hospital Charge Code |
1712631
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
THIOGUANINE 40 MG TABLET [7886]
|
Facility
OP
|
$30.33
|
|
|
Service Code
|
NDC 76388-880-25
|
| Hospital Charge Code |
1711149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$25.78 |
| Rate for Payer: Adventist Health Commercial |
$6.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22.75
|
| Rate for Payer: Blue Shield of California Commercial |
$18.83
|
| Rate for Payer: Blue Shield of California EPN |
$17.80
|
| Rate for Payer: Cash Price |
$13.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.78
|
| Rate for Payer: Dignity Health Senior |
$25.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.77
|
| Rate for Payer: Heritage Provider Network Senior |
$18.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$22.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: Vantage Medical Group Senior |
$25.78
|
|
|
THIOGUANINE 40 MG TABLET [7886]
|
Facility
IP
|
$30.33
|
|
|
Service Code
|
NDC 76388-880-25
|
| Hospital Charge Code |
1711149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Adventist Health Commercial |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.84
|
| Rate for Payer: Cash Price |
$13.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.53
|
| Rate for Payer: Heritage Provider Network Senior |
$20.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.58
|
| Rate for Payer: Multiplan Commercial |
$22.75
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
IP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
1715020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
THIOGUANINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080349]
|
Facility
OP
|
$6.03
|
|
|
Service Code
|
NDC 9994-0803-49
|
| Hospital Charge Code |
1715020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Blue Shield of California EPN |
$3.54
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
1710344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
THIORIDAZINE 25 MG TABLET [7899]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
1710344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
OP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.41 |
| Max. Negotiated Rate |
$4,230.00 |
| Rate for Payer: Adventist Health Commercial |
$1,128.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$494.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,874.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$219.41
|
| Rate for Payer: Blue Shield of California Commercial |
$636.21
|
| Rate for Payer: Blue Shield of California EPN |
$636.21
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,594.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: Dignity Health Senior |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,609.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$251.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,611.32
|
| Rate for Payer: Heritage Provider Network Senior |
$2,611.32
|
| Rate for Payer: Humana Medicare |
$251.20
|
| Rate for Payer: IEHP Medi-Cal |
$398.85
|
| Rate for Payer: IEHP Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$477.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,020.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,410.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$316.52
|
| Rate for Payer: Multiplan Commercial |
$4,230.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$276.33
|
| Rate for Payer: TriValley Medical Group Senior |
$251.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
IP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,020.84 |
| Max. Negotiated Rate |
$4,230.00 |
| Rate for Payer: Adventist Health Commercial |
$1,128.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,874.68
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,594.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,045.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,818.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3,818.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,020.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,410.00
|
| Rate for Payer: Multiplan Commercial |
$4,230.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.32
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
OP
|
$900.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
1755061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$494.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$219.41
|
| Rate for Payer: Blue Shield of California Commercial |
$636.21
|
| Rate for Payer: Blue Shield of California EPN |
$636.21
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: Dignity Health Senior |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$576.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$251.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$416.70
|
| Rate for Payer: Heritage Provider Network Senior |
$416.70
|
| Rate for Payer: Humana Medicare |
$251.20
|
| Rate for Payer: IEHP Medi-Cal |
$398.85
|
| Rate for Payer: IEHP Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$477.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$316.52
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$276.33
|
| Rate for Payer: TriValley Medical Group Senior |
$251.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
