|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$18.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
IP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
OP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.13
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 62559-722-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.51
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.51
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 62559-722-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.29
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.77
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$8.39 |
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$8.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.77
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$17.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.35
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$17.80 |
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
IP
|
$97.79
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.78 |
| Max. Negotiated Rate |
$78.23 |
| Rate for Payer: Cash Price |
$53.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.78
|
| Rate for Payer: Multiplan Commercial |
$73.34
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
OP
|
$97.79
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.78 |
| Max. Negotiated Rate |
$78.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$58.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$58.67
|
| Rate for Payer: Cash Price |
$53.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$78.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$58.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.78
|
| Rate for Payer: Multiplan Commercial |
$73.34
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
OP
|
$779.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$428.45 |
| Max. Negotiated Rate |
$623.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$467.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$467.40
|
| Rate for Payer: Cash Price |
$428.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$623.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$467.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$467.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$428.45
|
| Rate for Payer: Multiplan Commercial |
$584.25
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$779.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$428.45 |
| Max. Negotiated Rate |
$623.20 |
| Rate for Payer: Cash Price |
$428.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$623.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$467.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$428.45
|
| Rate for Payer: Multiplan Commercial |
$584.25
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$12.56 |
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.63
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.97
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$7.54 |
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$7.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$12.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.42
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.63
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
|
