|
THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES
|
Facility
IP
|
$12,026.31
|
|
|
Service Code
|
APR-DRG 4042
|
| Min. Negotiated Rate |
$12,026.31 |
| Max. Negotiated Rate |
$12,026.31 |
| Rate for Payer: IEHP Medi-Cal |
$12,026.31
|
|
|
THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES
|
Facility
IP
|
$8,197.95
|
|
|
Service Code
|
APR-DRG 4041
|
| Min. Negotiated Rate |
$8,197.95 |
| Max. Negotiated Rate |
$8,197.95 |
| Rate for Payer: IEHP Medi-Cal |
$8,197.95
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
OP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
1711089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| 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 Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
OP
|
$0.94
|
|
|
Service Code
|
NDC 0456-0457-01
|
| Hospital Charge Code |
1711089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
IP
|
$0.70
|
|
|
Service Code
|
NDC 42192-327-01
|
| Hospital Charge Code |
1711089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
THYROID (PORK) 15 MG TABLET [120628]
|
Facility
IP
|
$0.94
|
|
|
Service Code
|
NDC 0456-0457-01
|
| Hospital Charge Code |
1711089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
OP
|
$1.68
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
1711143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.43
|
| Rate for Payer: Dignity Health Senior |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1.43
|
|
|
THYROID (PORK) 180 MG TABLET [120633]
|
Facility
IP
|
$1.68
|
|
|
Service Code
|
NDC 0456-0462-01
|
| Hospital Charge Code |
1711143
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.15
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
IP
|
$2.40
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
1711155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
|
|
THYROID (PORK) 300 MG TABLET [120635]
|
Facility
OP
|
$2.40
|
|
|
Service Code
|
NDC 0456-0464-01
|
| Hospital Charge Code |
1711155
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.41
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Senior |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
IP
|
$0.83
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
1711096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
OP
|
$1.10
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
1711096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Senior |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
NDC 42192-329-01
|
| Hospital Charge Code |
1711096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
THYROID (PORK) 30 MG TABLET [120629]
|
Facility
IP
|
$1.10
|
|
|
Service Code
|
NDC 0456-0458-01
|
| Hospital Charge Code |
1711096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
1711108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
THYROID (PORK) 60 MG TABLET [120630]
|
Facility
OP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
1711108
|
|
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 Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| 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
IP
|
$0.92
|
|
|
Service Code
|
NDC 42192-330-01
|
| Hospital Charge Code |
1711108
|
|
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 |
$0.63
|
| 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 Permanente of CA 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
|
$1.22
|
|
|
Service Code
|
NDC 0456-0459-01
|
| Hospital Charge Code |
1711108
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
IP
|
$2,314.82
|
|
|
Service Code
|
CPT J3240
|
| Hospital Charge Code |
ERX24409
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$418.98 |
| Max. Negotiated Rate |
$1,736.12 |
| Rate for Payer: Adventist Health Commercial |
$462.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,590.28
|
| Rate for Payer: Cash Price |
$1,041.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,064.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,250.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,567.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1,567.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.70
|
| Rate for Payer: Multiplan Commercial |
$1,736.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$843.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$773.38
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [230836]
|
Facility
OP
|
$2,314.82
|
|
|
Service Code
|
CPT J3240
|
| Hospital Charge Code |
ERX24409
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$418.98 |
| Max. Negotiated Rate |
$4,965.25 |
| Rate for Payer: Adventist Health Commercial |
$462.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,965.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,590.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,526.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,223.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,223.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,062.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1,873.90
|
| Rate for Payer: Blue Shield of California EPN |
$1,873.90
|
| Rate for Payer: Cash Price |
$1,041.67
|
| Rate for Payer: Cash Price |
$1,041.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,064.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,031.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,223.29
|
| Rate for Payer: Dignity Health Senior |
$2,223.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,481.48
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,021.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,071.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1,071.76
|
| Rate for Payer: Humana Medicare |
$2,021.17
|
| Rate for Payer: IEHP Medi-Cal |
$3,159.98
|
| Rate for Payer: IEHP Medicare Advantage |
$2,021.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,840.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$418.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,384.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$578.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,546.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,546.67
|
| Rate for Payer: Multiplan Commercial |
$1,736.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,223.29
|
| Rate for Payer: TriValley Medical Group Senior |
$2,021.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$843.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$773.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,031.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,223.29
|
| Rate for Payer: Vantage Medical Group Senior |
$2,021.17
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
ERX211180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.44
|
| Rate for Payer: Blue Shield of California EPN |
$5.14
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: Dignity Health Senior |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 60 MG TABLET [211180]
|
Facility
IP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0776-60
|
| Hospital Charge Code |
ERX211180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.93
|
| Rate for Payer: Heritage Provider Network Senior |
$5.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.57
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.44
|
| Rate for Payer: Blue Shield of California EPN |
$5.14
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: Dignity Health Senior |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
OP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.57
|
| Rate for Payer: Blue Shield of California Commercial |
$5.44
|
| Rate for Payer: Blue Shield of California EPN |
$5.14
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.45
|
| Rate for Payer: Dignity Health Senior |
$7.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.45
|
| Rate for Payer: Vantage Medical Group Senior |
$7.45
|
|
|
TICAGRELOR 90 MG TABLET [153988]
|
Facility
IP
|
$8.76
|
|
|
Service Code
|
NDC 0186-0777-39
|
| Hospital Charge Code |
1712531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$6.57 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.93
|
| Rate for Payer: Heritage Provider Network Senior |
$5.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.19
|
| Rate for Payer: Multiplan Commercial |
$6.57
|
|
