|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
|
OP
|
$4,569.82
|
|
|
Service Code
|
CPT Q5117
|
| Hospital Charge Code |
ERX225307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,513.40 |
| Max. Negotiated Rate |
$3,427.36 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2,741.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2,741.89
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,741.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2,741.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,513.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,427.36
|
|
|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
|
IP
|
$4,569.82
|
|
|
Service Code
|
CPT Q5117
|
| Hospital Charge Code |
ERX225307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,513.40 |
| Max. Negotiated Rate |
$3,655.86 |
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,655.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$2,741.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,513.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3,427.36
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
OP
|
$60.37
|
|
|
Service Code
|
NDC 60505-0593-4
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$45.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.22
|
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.28
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
IP
|
$76.17
|
|
|
Service Code
|
NDC 0378-9651-32
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.89 |
| Max. Negotiated Rate |
$60.94 |
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$60.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.13
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
OP
|
$76.17
|
|
|
Service Code
|
NDC 0378-9651-32
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.89 |
| Max. Negotiated Rate |
$57.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$45.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$45.70
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$45.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$45.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.89
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.13
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
IP
|
$60.37
|
|
|
Service Code
|
NDC 60505-0593-4
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$48.30 |
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.28
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 50111-561-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 68382-806-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 50111-561-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 68382-806-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-11
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-11
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 68084-608-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 53489-517-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 68084-608-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 60687-432-11
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.41
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 68382-807-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 68382-807-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 53489-517-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.32
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 60687-432-11
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.52
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 60505-2653-1
|
| Hospital Charge Code |
1710068
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 68382-805-01
|
| Hospital Charge Code |
1710068
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 68382-805-01
|
| Hospital Charge Code |
1710068
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
