|
TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]
|
Facility
OP
|
$15.45
|
|
|
Service Code
|
NDC 0781-7171-84
|
| Hospital Charge Code |
1744078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$13.13 |
| Rate for Payer: Adventist Health Commercial |
$3.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.59
|
| Rate for Payer: Blue Shield of California Commercial |
$9.59
|
| Rate for Payer: Blue Shield of California EPN |
$9.07
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.13
|
| Rate for Payer: Dignity Health Senior |
$13.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.56
|
| Rate for Payer: Heritage Provider Network Senior |
$9.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$11.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.13
|
| Rate for Payer: Vantage Medical Group Senior |
$13.13
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| 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 |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
NDG7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: IEHP Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| 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 |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
IP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| 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 Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
OP
|
$1.19
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1757631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Senior |
$1.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: IEHP Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
IP
|
$0.88
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
OP
|
$0.86
|
|
|
Service Code
|
CPT J3260
|
| Hospital Charge Code |
1752244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$2.02
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.75
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: IEHP Medi-Cal |
$11.11
|
| Rate for Payer: IEHP Medi-Cal |
$11.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
OP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Adventist Health Commercial |
$16.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$69.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$61.62
|
| Rate for Payer: Blue Shield of California Commercial |
$51.02
|
| Rate for Payer: Blue Shield of California EPN |
$48.23
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.84
|
| Rate for Payer: Dignity Health Senior |
$69.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.86
|
| Rate for Payer: Heritage Provider Network Senior |
$50.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$61.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.84
|
| Rate for Payer: Vantage Medical Group Senior |
$69.84
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
IP
|
$82.16
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
1740289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$61.62 |
| Rate for Payer: Adventist Health Commercial |
$16.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.44
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.62
|
| Rate for Payer: Heritage Provider Network Senior |
$55.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$61.62
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| 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 |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| 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 |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 51672-2020-2
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| 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 |
$0.16
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 24385-032-03
|
| Hospital Charge Code |
NDG8020
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536-5150-26
|
| Hospital Charge Code |
1743283
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
IP
|
$0.49
|
|
|
Service Code
|
NDC 33342-097-09
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.70
|
| Rate for Payer: Dignity Health Senior |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093-0010-06
|
| Hospital Charge Code |
1711744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.18
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.38
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
IP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 33342-098-09
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 31722-806-60
|
| Hospital Charge Code |
1711745
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
IP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.78 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.22
|
| Rate for Payer: Heritage Provider Network Senior |
$5.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
|
|
TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR [29434]
|
Facility
OP
|
$7.71
|
|
|
Service Code
|
NDC 0093-7163-56
|
| Hospital Charge Code |
1711848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.79
|
| Rate for Payer: Blue Shield of California EPN |
$4.53
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.55
|
| Rate for Payer: Dignity Health Senior |
$6.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.77
|
| Rate for Payer: Heritage Provider Network Senior |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.93
|
| Rate for Payer: Multiplan Commercial |
$5.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.55
|
| Rate for Payer: Vantage Medical Group Senior |
$6.55
|
|
