|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]
|
Facility
OP
|
$10.40
|
|
|
Service Code
|
CPT J3301
|
| Hospital Charge Code |
1720190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$22.30 |
| Rate for Payer: Adventist Health Commercial |
$2.08
|
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Adventist Health Commercial |
$1.97
|
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cash Price |
$4.43
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cash Price |
$4.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Senior |
$9.69
|
| Rate for Payer: Dignity Health Senior |
$8.84
|
| Rate for Payer: Dignity Health Senior |
$8.37
|
| Rate for Payer: Dignity Health Senior |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.28
|
| Rate for Payer: Heritage Provider Network Senior |
$4.61
|
| Rate for Payer: Heritage Provider Network Senior |
$5.28
|
| Rate for Payer: Heritage Provider Network Senior |
$4.82
|
| Rate for Payer: Heritage Provider Network Senior |
$4.56
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.60
|
| Rate for Payer: Multiplan Commercial |
$7.39
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Multiplan Commercial |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.37
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.84
|
| Rate for Payer: Vantage Medical Group Senior |
$8.37
|
| Rate for Payer: Vantage Medical Group Senior |
$9.69
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]
|
Facility
OP
|
$9.71
|
|
|
Service Code
|
CPT J3301
|
| Hospital Charge Code |
1720077
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$22.30 |
| Rate for Payer: Adventist Health Commercial |
$1.94
|
| Rate for Payer: Adventist Health Commercial |
$2.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.01
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.25
|
| Rate for Payer: Dignity Health Senior |
$8.25
|
| Rate for Payer: Dignity Health Senior |
$8.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.72
|
| Rate for Payer: Heritage Provider Network Senior |
$4.50
|
| Rate for Payer: Heritage Provider Network Senior |
$4.72
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: IEHP Medi-Cal |
$8.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$7.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.25
|
| Rate for Payer: Vantage Medical Group Senior |
$8.67
|
| Rate for Payer: Vantage Medical Group Senior |
$8.25
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]
|
Facility
IP
|
$9.85
|
|
|
Service Code
|
CPT J3301
|
| Hospital Charge Code |
1720190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$7.39 |
| Rate for Payer: Adventist Health Commercial |
$1.97
|
| Rate for Payer: Adventist Health Commercial |
$2.08
|
| Rate for Payer: Adventist Health Commercial |
$2.28
|
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.83
|
| Rate for Payer: Cash Price |
$4.43
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cash Price |
$5.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.72
|
| Rate for Payer: Heritage Provider Network Senior |
$7.04
|
| Rate for Payer: Heritage Provider Network Senior |
$6.67
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Multiplan Commercial |
$7.39
|
| Rate for Payer: Multiplan Commercial |
$8.55
|
| Rate for Payer: Multiplan Commercial |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.33
|
|
|
TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL [19808]
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
NDC 4116758003
|
| Hospital Charge Code |
NDG19808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL [19808]
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
NDC 4116758003
|
| Hospital Charge Code |
NDG19808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML INTRAOCULAR SUSPENSION [89128]
|
Facility
IP
|
$193.31
|
|
|
Service Code
|
CPT J3300
|
| Hospital Charge Code |
1740433
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.99 |
| Max. Negotiated Rate |
$144.98 |
| Rate for Payer: Adventist Health Commercial |
$38.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$132.80
|
| Rate for Payer: Cash Price |
$86.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.87
|
| Rate for Payer: Heritage Provider Network Senior |
$130.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.33
|
| Rate for Payer: Multiplan Commercial |
$144.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$70.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$64.58
|
|
|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML INTRAOCULAR SUSPENSION [89128]
|
Facility
OP
|
$193.31
|
|
|
Service Code
|
CPT J3300
|
| Hospital Charge Code |
1740433
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$164.31 |
| Rate for Payer: Adventist Health Commercial |
$38.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$132.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$164.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$106.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$144.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.93
|
| Rate for Payer: Blue Shield of California Commercial |
$4.03
|
| Rate for Payer: Blue Shield of California EPN |
$4.03
|
| Rate for Payer: Cash Price |
$86.99
|
| Rate for Payer: Cash Price |
$86.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$88.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$164.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$164.31
|
| Rate for Payer: Dignity Health Senior |
$164.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$123.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.50
|
| Rate for Payer: Heritage Provider Network Senior |
$89.50
|
| Rate for Payer: IEHP Medi-Cal |
$13.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$93.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.33
|
| Rate for Payer: Multiplan Commercial |
$144.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$70.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$64.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$164.31
|
| Rate for Payer: Vantage Medical Group Senior |
$164.31
|
|
|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML SUPRACHOROIDAL SUSPENSION [235246]
|
Facility
IP
|
$2,200.00
|
|
|
Service Code
|
CPT J3299
|
| Hospital Charge Code |
NDG235246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$398.20 |
| Max. Negotiated Rate |
$1,650.00 |
| Rate for Payer: Adventist Health Commercial |
$440.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,511.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,012.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,188.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,489.40
|
| Rate for Payer: Heritage Provider Network Senior |
$1,489.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$398.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$550.00
|
| Rate for Payer: Multiplan Commercial |
$1,650.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$802.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$735.02
|
|
|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML SUPRACHOROIDAL SUSPENSION [235246]
|
Facility
OP
|
$2,200.00
|
|
|
Service Code
|
CPT J3299
|
| Hospital Charge Code |
NDG235246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$1,650.00 |
| Rate for Payer: Adventist Health Commercial |
$440.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$119.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,511.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$60.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$53.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$53.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.93
|
| Rate for Payer: Blue Shield of California Commercial |
$46.75
|
| Rate for Payer: Blue Shield of California EPN |
$46.75
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,012.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.44
|
| Rate for Payer: Dignity Health Senior |
$53.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,408.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,018.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,018.60
|
| Rate for Payer: Humana Medicare |
$48.58
|
| Rate for Payer: IEHP Medi-Cal |
$82.74
|
| Rate for Payer: IEHP Medicare Advantage |
$48.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$92.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$398.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$550.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$61.21
|
| Rate for Payer: Multiplan Commercial |
$1,650.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$53.44
|
| Rate for Payer: TriValley Medical Group Senior |
$48.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$802.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$735.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.44
|
| Rate for Payer: Vantage Medical Group Senior |
$53.44
|
|
|
TRIAMCINOLONE MOXIFLOXACIN VANCOMYCIN (TRI-MOXI-VANC) OPHTHALMIC INJECTION [4081389]
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX4081389
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.35
|
|
|
TRIAMCINOLONE MOXIFLOXACIN VANCOMYCIN (TRI-MOXI-VANC) OPHTHALMIC INJECTION [4081389]
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
ERX4081389
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$21.25 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$18.75
|
| Rate for Payer: Blue Shield of California Commercial |
$15.52
|
| Rate for Payer: Blue Shield of California EPN |
$14.68
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.25
|
| Rate for Payer: Dignity Health Senior |
$21.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.58
|
| Rate for Payer: Heritage Provider Network Senior |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.25
|
| Rate for Payer: Vantage Medical Group Senior |
$21.25
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-20
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| 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 Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 72578-090-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-10
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 72578-090-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| 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 Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 0781-2074-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-10
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 0781-2074-10
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| 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 |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 0781-2074-10
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 51079-935-20
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 0378-2537-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 0781-2074-01
|
| Hospital Charge Code |
1711917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| 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 Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
