|
Tissue expander placement in breast reconstruction, including subsequent expansion(s)
|
Facility
OP
|
$41,833.08
|
|
|
Service Code
|
CPT 19357
|
| Min. Negotiated Rate |
$221.29 |
| Max. Negotiated Rate |
$41,833.08 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33,026.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24,219.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$22,017.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33,026.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$24,219.15
|
| Rate for Payer: Dignity Health Senior |
$22,017.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$22,017.41
|
| Rate for Payer: Humana Medicare |
$22,017.41
|
| Rate for Payer: IEHP Medi-Cal |
$221.29
|
| Rate for Payer: IEHP Medicare Advantage |
$22,017.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41,833.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25,980.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27,741.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27,741.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$24,219.15
|
| Rate for Payer: TriValley Medical Group Senior |
$22,017.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33,026.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24,219.15
|
| Rate for Payer: Vantage Medical Group Senior |
$22,017.41
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 60505-0251-3
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 60505-0251-3
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
IP
|
$1.29
|
|
|
Service Code
|
NDC 68084-775-95
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
OP
|
$1.29
|
|
|
Service Code
|
NDC 68084-775-25
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
OP
|
$1.29
|
|
|
Service Code
|
NDC 68084-775-95
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
TIZANIDINE 2 MG TABLET [14792]
|
Facility
IP
|
$1.29
|
|
|
Service Code
|
NDC 68084-775-25
|
| Hospital Charge Code |
1712365
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.97
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 29300-169-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 55111-180-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.24
|
|
|
Service Code
|
NDC 60505-0252-3
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| 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 |
$0.18
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
NDC 0904-6418-61
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| 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 |
$0.43
|
| 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 |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| 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 |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.12
|
|
|
Service Code
|
NDC 55111-180-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-11
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.79
|
|
|
Service Code
|
NDC 50268-760-11
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| 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 Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.12
|
|
|
Service Code
|
NDC 29300-169-15
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 60505-0252-3
|
| Hospital Charge Code |
1710900
|
|
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 |
$0.13
|
| 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 |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| 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 |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| 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 |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
TIZANIDINE 4 MG TABLET [14793]
|
Facility
IP
|
$0.63
|
|
|
Service Code
|
NDC 0904-6418-61
|
| Hospital Charge Code |
1710900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| 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 |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
OP
|
$39.97
|
|
|
Service Code
|
NDC 0065-0647-05
|
| Hospital Charge Code |
NDG11567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$33.97 |
| Rate for Payer: Adventist Health Commercial |
$7.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$29.98
|
| Rate for Payer: Blue Shield of California Commercial |
$24.82
|
| Rate for Payer: Blue Shield of California EPN |
$23.46
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.97
|
| Rate for Payer: Dignity Health Senior |
$33.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.74
|
| Rate for Payer: Heritage Provider Network Senior |
$24.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.99
|
| Rate for Payer: Multiplan Commercial |
$29.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.97
|
| Rate for Payer: Vantage Medical Group Senior |
$33.97
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
OP
|
$24.34
|
|
|
Service Code
|
NDC 24208-295-05
|
| Hospital Charge Code |
NDG11567
|
|
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
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
IP
|
$39.97
|
|
|
Service Code
|
NDC 0065-0647-05
|
| Hospital Charge Code |
NDG11567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$29.98 |
| Rate for Payer: Adventist Health Commercial |
$7.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.46
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.06
|
| Rate for Payer: Heritage Provider Network Senior |
$27.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.99
|
| Rate for Payer: Multiplan Commercial |
$29.98
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
IP
|
$24.34
|
|
|
Service Code
|
NDC 24208-295-05
|
| Hospital Charge Code |
NDG11567
|
|
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
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
IP
|
$18.21
|
|
|
Service Code
|
NDC 0574-4031-25
|
| Hospital Charge Code |
1740306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$13.66 |
| Rate for Payer: Adventist Health Commercial |
$3.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.51
|
| Rate for Payer: Cash Price |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.33
|
| Rate for Payer: Heritage Provider Network Senior |
$12.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$13.66
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
OP
|
$18.21
|
|
|
Service Code
|
NDC 0574-4031-25
|
| Hospital Charge Code |
1740306
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Adventist Health Commercial |
$3.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.66
|
| Rate for Payer: Blue Shield of California Commercial |
$11.31
|
| Rate for Payer: Blue Shield of California EPN |
$10.69
|
| Rate for Payer: Cash Price |
$8.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.48
|
| Rate for Payer: Dignity Health Senior |
$15.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.27
|
| Rate for Payer: Heritage Provider Network Senior |
$11.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.55
|
| Rate for Payer: Multiplan Commercial |
$13.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.48
|
| Rate for Payer: Vantage Medical Group Senior |
$15.48
|
|
