|
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
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
IP
|
$124.80
|
|
|
Service Code
|
CPT J3243
|
| Hospital Charge Code |
1753538
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Adventist Health Commercial |
$24.96
|
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$30.05
|
| Rate for Payer: Adventist Health Commercial |
$38.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.96
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$102.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$129.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.71
|
| Rate for Payer: Heritage Provider Network Senior |
$84.49
|
| Rate for Payer: Heritage Provider Network Senior |
$129.06
|
| Rate for Payer: Heritage Provider Network Senior |
$85.30
|
| Rate for Payer: Heritage Provider Network Senior |
$48.74
|
| Rate for Payer: Heritage Provider Network Senior |
$101.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.56
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$112.68
|
| Rate for Payer: Multiplan Commercial |
$142.97
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$69.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION [41652]
|
Facility
OP
|
$190.63
|
|
|
Service Code
|
CPT J3243
|
| Hospital Charge Code |
1753538
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$162.04 |
| Rate for Payer: Adventist Health Commercial |
$38.13
|
| Rate for Payer: Adventist Health Commercial |
$14.40
|
| Rate for Payer: Adventist Health Commercial |
$24.96
|
| Rate for Payer: Adventist Health Commercial |
$25.20
|
| Rate for Payer: Adventist Health Commercial |
$30.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$86.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$107.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$127.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$106.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$61.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$68.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$104.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$82.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$94.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$112.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$142.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$93.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cash Price |
$67.61
|
| Rate for Payer: Cash Price |
$85.78
|
| Rate for Payer: Cash Price |
$56.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$106.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$127.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$127.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$106.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.04
|
| Rate for Payer: Dignity Health Senior |
$106.08
|
| Rate for Payer: Dignity Health Senior |
$107.10
|
| Rate for Payer: Dignity Health Senior |
$127.70
|
| Rate for Payer: Dignity Health Senior |
$162.04
|
| Rate for Payer: Dignity Health Senior |
$61.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$57.78
|
| Rate for Payer: Heritage Provider Network Senior |
$58.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.34
|
| Rate for Payer: Heritage Provider Network Senior |
$69.56
|
| Rate for Payer: Heritage Provider Network Senior |
$88.26
|
| Rate for Payer: IEHP Medi-Cal |
$8.11
|
| Rate for Payer: IEHP Medi-Cal |
$8.11
|
| Rate for Payer: IEHP Medi-Cal |
$8.11
|
| Rate for Payer: IEHP Medi-Cal |
$8.11
|
| Rate for Payer: IEHP Medi-Cal |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$91.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$60.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.20
|
| Rate for Payer: Multiplan Commercial |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$142.97
|
| Rate for Payer: Multiplan Commercial |
$112.68
|
| Rate for Payer: Multiplan Commercial |
$54.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$45.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$69.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$41.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$106.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$127.70
|
| Rate for Payer: Vantage Medical Group Senior |
$162.04
|
| Rate for Payer: Vantage Medical Group Senior |
$127.70
|
| Rate for Payer: Vantage Medical Group Senior |
$107.10
|
| Rate for Payer: Vantage Medical Group Senior |
$106.08
|
| Rate for Payer: Vantage Medical Group Senior |
$61.20
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 60758-802-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| 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 |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| 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 |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
NDG11561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
NDG11561
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS [11561]
|
Facility
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
1740182
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| 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 |
$0.93
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
IP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
OP
|
$2.33
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.98
|
| Rate for Payer: Dignity Health Senior |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
IP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.59
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Senior |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS [11562]
|
Facility
OP
|
$2.32
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
1740181
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California EPN |
$1.36
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.97
|
| Rate for Payer: Dignity Health Senior |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: Vantage Medical Group Senior |
$1.97
|
|
|
TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]
|
Facility
OP
|
$24.34
|
|
|
Service Code
|
NDC 0597-0075-75
|
| Hospital Charge Code |
1744109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Adventist Health Commercial |
$4.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$20.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.26
|
| Rate for Payer: Blue Shield of California Commercial |
$15.12
|
| Rate for Payer: Blue Shield of California EPN |
$14.29
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.69
|
| Rate for Payer: Dignity Health Senior |
$20.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.07
|
| Rate for Payer: Heritage Provider Network Senior |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.08
|
| Rate for Payer: Multiplan Commercial |
$18.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.69
|
| Rate for Payer: Vantage Medical Group Senior |
$20.69
|
|
|
TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE [38315]
|
Facility
IP
|
$24.34
|
|
|
Service Code
|
NDC 0597-0075-75
|
| Hospital Charge Code |
1744109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$18.26 |
| Rate for Payer: Adventist Health Commercial |
$4.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.72
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.48
|
| Rate for Payer: Heritage Provider Network Senior |
$16.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.08
|
| Rate for Payer: Multiplan Commercial |
$18.26
|
|
|
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]
|
Facility
IP
|
$22.50
|
|
|
Service Code
|
NDC 0597-0100-51
|
| Hospital Charge Code |
ERX207738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.23
|
| Rate for Payer: Heritage Provider Network Senior |
$15.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
|
|
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION [207738]
|
Facility
OP
|
$22.50
|
|
|
Service Code
|
NDC 0597-0100-51
|
| Hospital Charge Code |
ERX207738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$19.12 |
| Rate for Payer: Adventist Health Commercial |
$4.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.88
|
| Rate for Payer: Blue Shield of California Commercial |
$13.97
|
| Rate for Payer: Blue Shield of California EPN |
$13.21
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.12
|
| Rate for Payer: Dignity Health Senior |
$19.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.93
|
| Rate for Payer: Heritage Provider Network Senior |
$13.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.62
|
| Rate for Payer: Multiplan Commercial |
$16.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.12
|
| Rate for Payer: Vantage Medical Group Senior |
$19.12
|
|
|
TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [120194]
|
Facility
IP
|
$1.15
|
|
|
Service Code
|
CPT J3246
|
| Hospital Charge Code |
NDG120194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.79
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
|
|
TIROFIBAN 12.5 MG/250 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [120194]
|
Facility
OP
|
$1.15
|
|
|
Service Code
|
CPT J3246
|
| Hospital Charge Code |
NDG120194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.75
|
| Rate for Payer: Dignity Health Senior |
$4.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Humana Medicare |
$4.32
|
| Rate for Payer: IEHP Medicare Advantage |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.44
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4.32
|
|
|
TIROFIBAN 5 MG/100 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [23050]
|
Facility
OP
|
$1.10
|
|
|
Service Code
|
CPT J3246
|
| Hospital Charge Code |
NDG23050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.81
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.75
|
| Rate for Payer: Dignity Health Senior |
$4.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Senior |
$0.51
|
| Rate for Payer: Humana Medicare |
$4.32
|
| Rate for Payer: IEHP Medicare Advantage |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.44
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4.32
|
|
|
TIROFIBAN 5 MG/100 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS [23050]
|
Facility
IP
|
$1.10
|
|
|
Service Code
|
CPT J3246
|
| Hospital Charge Code |
NDG23050
|
|
Hospital Revenue Code
|
636
|
| 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: Cigna of CA HMO/PPO |
$0.51
|
| 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
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
|
|
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION [232793]
|
Facility
IP
|
$7,622.40
|
|
|
Service Code
|
NDC 51144-003-01
|
| Hospital Charge Code |
ERX232793
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,379.65 |
| Max. Negotiated Rate |
$5,716.80 |
| Rate for Payer: Adventist Health Commercial |
$1,524.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,236.59
|
| Rate for Payer: Cash Price |
$3,430.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,506.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,116.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,160.36
|
| Rate for Payer: Heritage Provider Network Senior |
$5,160.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,379.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,905.60
|
| Rate for Payer: Multiplan Commercial |
$5,716.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,779.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,546.64
|
|
|
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION [232793]
|
Facility
OP
|
$7,622.40
|
|
|
Service Code
|
NDC 51144-003-01
|
| Hospital Charge Code |
ERX232793
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,379.65 |
| Max. Negotiated Rate |
$6,479.04 |
| Rate for Payer: Adventist Health Commercial |
$1,524.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,074.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,236.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,479.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,192.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,716.80
|
| Rate for Payer: Blue Shield of California Commercial |
$4,733.51
|
| Rate for Payer: Blue Shield of California EPN |
$4,474.35
|
| Rate for Payer: Cash Price |
$3,430.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,506.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,479.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$6,479.04
|
| Rate for Payer: Dignity Health Senior |
$6,479.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,878.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,529.17
|
| Rate for Payer: Heritage Provider Network Senior |
$3,529.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,674.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,379.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,905.60
|
| Rate for Payer: Multiplan Commercial |
$5,716.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,779.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,546.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6,479.04
|
| Rate for Payer: Vantage Medical Group Senior |
$6,479.04
|
|
