|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 65862-538-20
|
| Hospital Charge Code |
1712271
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| 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: Multiplan Commercial |
$0.65
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-79
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
|
|
LEVONORGESTREL 0.15 MG-ETHINYL ESTRADIOL 0.03 MG TABLET [10401]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 0555-9020-58
|
| Hospital Charge Code |
1712577
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.84
|
| Rate for Payer: Dignity Health Senior |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
OP
|
$1,322.04
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX216252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.89 |
| Max. Negotiated Rate |
$991.53 |
| Rate for Payer: Adventist Health Commercial |
$264.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$908.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$120.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$105.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.67
|
| Rate for Payer: Blue Shield of California Commercial |
$91.89
|
| Rate for Payer: Blue Shield of California EPN |
$91.89
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$608.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$105.63
|
| Rate for Payer: Dignity Health Senior |
$105.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$846.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$96.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$612.10
|
| Rate for Payer: Heritage Provider Network Senior |
$612.10
|
| Rate for Payer: Humana Medicare |
$96.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$156.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$96.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$239.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$330.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$120.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$120.99
|
| Rate for Payer: Multiplan Commercial |
$991.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$528.82
|
| Rate for Payer: TriValley Medical Group Senior |
$528.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$482.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$441.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$144.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.63
|
| Rate for Payer: Vantage Medical Group Senior |
$96.03
|
|
|
LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE [216252]
|
Facility
|
IP
|
$1,322.04
|
|
|
Service Code
|
CPT J2796
|
| Hospital Charge Code |
ERX216252
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$239.29 |
| Max. Negotiated Rate |
$991.53 |
| Rate for Payer: Adventist Health Commercial |
$264.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$908.24
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$608.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$713.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$895.02
|
| Rate for Payer: Heritage Provider Network Senior |
$895.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$239.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$330.51
|
| Rate for Payer: Multiplan Commercial |
$991.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$482.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$441.69
|
|
|
LEVONORGESTREL 20.4 MCG/24 HRS (8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
IP
|
$1,014.12
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
ERX205847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.56 |
| Max. Negotiated Rate |
$760.59 |
| Rate for Payer: Adventist Health Commercial |
$202.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$696.70
|
| Rate for Payer: Cash Price |
$456.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$466.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$686.56
|
| Rate for Payer: Heritage Provider Network Senior |
$686.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$183.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.53
|
| Rate for Payer: Multiplan Commercial |
$760.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$369.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$338.82
|
|
|
LEVONORGESTREL 20.4 MCG/24 HRS (8 YRS) 52 MG INTRAUTERINE DEVICE [205847]
|
Facility
|
OP
|
$1,014.12
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
ERX205847
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.56 |
| Max. Negotiated Rate |
$2,055.54 |
| Rate for Payer: Adventist Health Commercial |
$202.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,055.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$696.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$862.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$557.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$760.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,335.71
|
| Rate for Payer: Blue Shield of California Commercial |
$862.00
|
| Rate for Payer: Blue Shield of California EPN |
$862.00
|
| Rate for Payer: Cash Price |
$456.35
|
| Rate for Payer: Cash Price |
$456.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$466.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$862.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$862.00
|
| Rate for Payer: Dignity Health Senior |
$862.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$649.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$469.54
|
| Rate for Payer: Heritage Provider Network Senior |
$469.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,318.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$488.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$183.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.53
|
| Rate for Payer: Multiplan Commercial |
$760.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$405.65
|
| Rate for Payer: TriValley Medical Group Senior |
$405.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$369.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$338.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$862.00
|
| Rate for Payer: Vantage Medical Group Senior |
$862.00
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
|
OP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$239.29 |
| Max. Negotiated Rate |
$2,679.66 |
| Rate for Payer: Adventist Health Commercial |
$264.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,679.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$908.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,123.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$727.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$991.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,732.14
|
| Rate for Payer: Blue Shield of California Commercial |
$1,070.23
|
| Rate for Payer: Blue Shield of California EPN |
$1,070.23
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$608.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,123.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,123.73
|
| Rate for Payer: Dignity Health Senior |
$1,123.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$846.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$612.10
|
| Rate for Payer: Heritage Provider Network Senior |
$612.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,804.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$637.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$239.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$330.51
|
| Rate for Payer: Multiplan Commercial |
$991.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$528.82
|
| Rate for Payer: TriValley Medical Group Senior |
$528.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$482.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$441.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,123.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1,123.73
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE [29280]
|
Facility
|
IP
|
$1,322.04
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
1712419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$239.29 |
| Max. Negotiated Rate |
$991.53 |
| Rate for Payer: Adventist Health Commercial |
$264.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$908.24
|
| Rate for Payer: Cash Price |
$594.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$608.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$713.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$895.02
|
| Rate for Payer: Heritage Provider Network Senior |
$895.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$239.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$330.51
|
| Rate for Payer: Multiplan Commercial |
$991.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$482.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$441.69
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.53 |
| Max. Negotiated Rate |
$85.05 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.91
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.77
|
| Rate for Payer: Heritage Provider Network Senior |
$76.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.02
|
| Rate for Payer: Blue Shield of California Commercial |
$78.68
|
| Rate for Payer: Blue Shield of California EPN |
$74.37
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.70
|
| Rate for Payer: Dignity Health Senior |
$107.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.43
|
| Rate for Payer: Heritage Provider Network Senior |
$78.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$61.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: Multiplan Commercial |
$95.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.68
|
| Rate for Payer: TriValley Medical Group Senior |
$50.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.70
|
| Rate for Payer: Vantage Medical Group Senior |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$107.70 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$67.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$107.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.02
|
| Rate for Payer: Blue Shield of California Commercial |
$78.68
|
| Rate for Payer: Blue Shield of California EPN |
$74.37
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$107.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$107.70
|
| Rate for Payer: Dignity Health Senior |
$107.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.43
|
| Rate for Payer: Heritage Provider Network Senior |
$78.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$61.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: Multiplan Commercial |
$95.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$50.68
|
| Rate for Payer: TriValley Medical Group Senior |
$50.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$107.70
|
| Rate for Payer: Vantage Medical Group Senior |
$107.70
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.53 |
| Max. Negotiated Rate |
$96.39 |
| Rate for Payer: Adventist Health Commercial |
$22.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.05
|
| Rate for Payer: Blue Shield of California Commercial |
$70.42
|
| Rate for Payer: Blue Shield of California EPN |
$66.57
|
| Rate for Payer: Cash Price |
$51.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.39
|
| Rate for Payer: Dignity Health Senior |
$96.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.19
|
| Rate for Payer: Heritage Provider Network Senior |
$70.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$54.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.35
|
| Rate for Payer: Multiplan Commercial |
$85.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.36
|
| Rate for Payer: TriValley Medical Group Senior |
$45.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.39
|
| Rate for Payer: Vantage Medical Group Senior |
$96.39
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$126.70
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$95.02 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.04
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.78
|
| Rate for Payer: Heritage Provider Network Senior |
$85.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: Multiplan Commercial |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [152916]
|
Facility
|
IP
|
$126.70
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
1721207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$95.02 |
| Rate for Payer: Adventist Health Commercial |
$25.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$87.04
|
| Rate for Payer: Cash Price |
$57.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.78
|
| Rate for Payer: Heritage Provider Network Senior |
$85.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.68
|
| Rate for Payer: Multiplan Commercial |
$95.02
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 68180-969-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| 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 |
$0.09
|
| 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: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 0074-6624-90
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 69238-1834-1
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 0074-6624-90
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-11
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 60687-497-01
|
| Hospital Charge Code |
1710605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
