|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
IP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
1711328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Blue Shield of California Commercial |
$3.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO |
$3.65
|
| Rate for Payer: Cigna of CA PPO |
$3.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: Galaxy Health WC |
$4.44
|
| Rate for Payer: Global Benefits Group Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$4.18
|
| Rate for Payer: Networks By Design Commercial |
$3.39
|
| Rate for Payer: Prime Health Services Commercial |
$4.44
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
1711328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.80
|
| Rate for Payer: Blue Distinction Transplant |
$3.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.70
|
| Rate for Payer: Blue Shield of California EPN |
$3.73
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.42
|
| Rate for Payer: Dignity Health Media |
$5.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.55
|
| Rate for Payer: Galaxy Health WC |
$5.42
|
| Rate for Payer: Global Benefits Group Commercial |
$3.83
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.10
|
| Rate for Payer: Networks By Design Commercial |
$4.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.19
|
| Rate for Payer: United Healthcare All Other HMO |
$3.19
|
| Rate for Payer: United Healthcare HMO Rider |
$3.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Vantage Medical Group Senior |
$5.42
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Blue Shield of California Commercial |
$4.54
|
| Rate for Payer: Blue Shield of California EPN |
$3.27
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: Galaxy Health WC |
$5.42
|
| Rate for Payer: Global Benefits Group Commercial |
$3.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: Multiplan Commercial |
$5.10
|
| Rate for Payer: Networks By Design Commercial |
$4.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.42
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: Blue Distinction Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.75
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Media |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX235956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$273.60 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$747.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$969.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$627.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$627.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$679.21
|
| Rate for Payer: Blue Distinction Transplant |
$684.00
|
| Rate for Payer: Blue Shield of California Commercial |
$840.18
|
| Rate for Payer: Blue Shield of California EPN |
$665.76
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cigna of CA HMO |
$798.00
|
| Rate for Payer: Cigna of CA PPO |
$798.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$969.00
|
| Rate for Payer: Dignity Health Media |
$969.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$969.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$456.00
|
| Rate for Payer: Galaxy Health WC |
$969.00
|
| Rate for Payer: Global Benefits Group Commercial |
$684.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$855.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$760.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$434.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.60
|
| Rate for Payer: Multiplan Commercial |
$912.00
|
| Rate for Payer: Networks By Design Commercial |
$570.00
|
| Rate for Payer: Prime Health Services Commercial |
$969.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$684.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$684.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$570.00
|
| Rate for Payer: United Healthcare All Other HMO |
$570.00
|
| Rate for Payer: United Healthcare HMO Rider |
$570.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$570.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$969.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$969.00
|
| Rate for Payer: Vantage Medical Group Senior |
$969.00
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX235956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$273.60 |
| Max. Negotiated Rate |
$969.00 |
| Rate for Payer: Blue Shield of California Commercial |
$811.68
|
| Rate for Payer: Blue Shield of California EPN |
$583.68
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cigna of CA HMO |
$798.00
|
| Rate for Payer: Cigna of CA PPO |
$798.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$456.00
|
| Rate for Payer: Galaxy Health WC |
$969.00
|
| Rate for Payer: Global Benefits Group Commercial |
$684.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$760.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$434.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.60
|
| Rate for Payer: Multiplan Commercial |
$912.00
|
| Rate for Payer: Networks By Design Commercial |
$570.00
|
| Rate for Payer: Prime Health Services Commercial |
$969.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$430.46
|
| Rate for Payer: United Healthcare All Other HMO |
$420.43
|
| Rate for Payer: United Healthcare HMO Rider |
$411.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$376.20
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
OP
|
$9.26
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1720036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Distinction Transplant |
$5.56
|
| Rate for Payer: Blue Shield of California Commercial |
$6.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna of CA HMO |
$6.48
|
| Rate for Payer: Cigna of CA PPO |
$6.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.87
|
| Rate for Payer: Dignity Health Media |
$7.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.70
|
| Rate for Payer: Galaxy Health WC |
$7.87
|
| Rate for Payer: Global Benefits Group Commercial |
$5.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$7.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Other HMO |
$4.63
|
| Rate for Payer: United Healthcare HMO Rider |
$4.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.87
|
| Rate for Payer: Vantage Medical Group Senior |
$7.87
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
IP
|
$9.26
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1720036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Blue Shield of California Commercial |
$6.59
|
| Rate for Payer: Blue Shield of California EPN |
$4.74
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna of CA HMO |
$6.48
|
| Rate for Payer: Cigna of CA PPO |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.70
|
| Rate for Payer: Galaxy Health WC |
$7.87
|
| Rate for Payer: Global Benefits Group Commercial |
$5.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.22
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$7.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.42
|
| Rate for Payer: United Healthcare HMO Rider |
$3.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.06
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1790026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Distinction Transplant |
$13.35
|
| Rate for Payer: Blue Shield of California Commercial |
$16.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Cigna of CA HMO |
$15.58
|
| Rate for Payer: Cigna of CA PPO |
$15.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.91
|
| Rate for Payer: Dignity Health Media |
$18.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.90
|
| Rate for Payer: Galaxy Health WC |
$18.91
|
| Rate for Payer: Global Benefits Group Commercial |
$13.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$16.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$17.80
|
| Rate for Payer: Networks By Design Commercial |
$11.12
|
| Rate for Payer: Prime Health Services Commercial |
$18.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.12
|
| Rate for Payer: United Healthcare All Other HMO |
$11.12
|
| Rate for Payer: United Healthcare HMO Rider |
$11.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.91
|
| Rate for Payer: Vantage Medical Group Senior |
$18.91
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1790026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Blue Shield of California Commercial |
$15.84
|
| Rate for Payer: Blue Shield of California EPN |
$11.39
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Cigna of CA HMO |
$15.58
|
| Rate for Payer: Cigna of CA PPO |
$15.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.90
|
| Rate for Payer: Galaxy Health WC |
$18.91
|
| Rate for Payer: Global Benefits Group Commercial |
$13.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$17.80
|
| Rate for Payer: Networks By Design Commercial |
$11.12
|
| Rate for Payer: Prime Health Services Commercial |
$18.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.40
|
| Rate for Payer: United Healthcare All Other HMO |
$8.21
|
| Rate for Payer: United Healthcare HMO Rider |
$8.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.34
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
OP
|
$91.77
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
1721039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.02 |
| Max. Negotiated Rate |
$210.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$210.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$50.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43.40
|
| Rate for Payer: Blue Distinction Transplant |
$55.06
|
| Rate for Payer: Blue Shield of California Commercial |
$67.63
|
| Rate for Payer: Blue Shield of California EPN |
$31.06
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cigna of CA HMO |
$64.24
|
| Rate for Payer: Cigna of CA PPO |
$64.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: Dignity Health Media |
$78.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$78.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.71
|
| Rate for Payer: Galaxy Health WC |
$78.00
|
| Rate for Payer: Global Benefits Group Commercial |
$55.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$68.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.02
|
| Rate for Payer: Multiplan Commercial |
$73.42
|
| Rate for Payer: Networks By Design Commercial |
$45.88
|
| Rate for Payer: Prime Health Services Commercial |
$78.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.88
|
| Rate for Payer: United Healthcare All Other HMO |
$45.88
|
| Rate for Payer: United Healthcare HMO Rider |
$45.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$78.00
|
| Rate for Payer: Vantage Medical Group Senior |
$78.00
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
IP
|
$91.77
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
1721039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.02 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Blue Shield of California Commercial |
$65.34
|
| Rate for Payer: Blue Shield of California EPN |
$46.99
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cigna of CA HMO |
$64.24
|
| Rate for Payer: Cigna of CA PPO |
$64.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.71
|
| Rate for Payer: Galaxy Health WC |
$78.00
|
| Rate for Payer: Global Benefits Group Commercial |
$55.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.02
|
| Rate for Payer: Multiplan Commercial |
$73.42
|
| Rate for Payer: Networks By Design Commercial |
$45.88
|
| Rate for Payer: Prime Health Services Commercial |
$78.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$34.65
|
| Rate for Payer: United Healthcare All Other HMO |
$33.84
|
| Rate for Payer: United Healthcare HMO Rider |
$33.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.28
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
|
IP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$57.09 |
| Rate for Payer: Blue Shield of California Commercial |
$47.82
|
| Rate for Payer: Blue Shield of California EPN |
$34.39
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.86
|
| Rate for Payer: Galaxy Health WC |
$57.09
|
| Rate for Payer: Global Benefits Group Commercial |
$40.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.12
|
| Rate for Payer: Multiplan Commercial |
$53.73
|
| Rate for Payer: Networks By Design Commercial |
$43.65
|
| Rate for Payer: Prime Health Services Commercial |
$57.09
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
|
OP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$57.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$44.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40.01
|
| Rate for Payer: Blue Distinction Transplant |
$40.30
|
| Rate for Payer: Blue Shield of California Commercial |
$49.50
|
| Rate for Payer: Blue Shield of California EPN |
$39.22
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Cigna of CA HMO |
$42.98
|
| Rate for Payer: Cigna of CA PPO |
$49.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.09
|
| Rate for Payer: Dignity Health Media |
$57.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.86
|
| Rate for Payer: Galaxy Health WC |
$57.09
|
| Rate for Payer: Global Benefits Group Commercial |
$40.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$50.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.12
|
| Rate for Payer: Multiplan Commercial |
$53.73
|
| Rate for Payer: Networks By Design Commercial |
$43.65
|
| Rate for Payer: Prime Health Services Commercial |
$57.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.58
|
| Rate for Payer: United Healthcare All Other HMO |
$33.58
|
| Rate for Payer: United Healthcare HMO Rider |
$33.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.09
|
| Rate for Payer: Vantage Medical Group Senior |
$57.09
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
OP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.51 |
| Max. Negotiated Rate |
$3,639.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,639.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$723.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$636.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$213.17
|
| Rate for Payer: Blue Distinction Transplant |
$453.79
|
| Rate for Payer: Blue Shield of California Commercial |
$557.40
|
| Rate for Payer: Blue Shield of California EPN |
$667.68
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cigna of CA HMO |
$529.42
|
| Rate for Payer: Cigna of CA PPO |
$529.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$867.92
|
| Rate for Payer: Dignity Health Media |
$578.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$636.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$781.13
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$578.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$578.61
|
| Rate for Payer: Galaxy Health WC |
$642.86
|
| Rate for Payer: Global Benefits Group Commercial |
$453.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$567.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$948.93
|
| Rate for Payer: Heritage Provider Network Transplant |
$948.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$937.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$937.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$578.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,107.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$578.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$729.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$775.34
|
| Rate for Payer: Multiplan Commercial |
$605.05
|
| Rate for Payer: Networks By Design Commercial |
$378.16
|
| Rate for Payer: Prime Health Services Commercial |
$642.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$453.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$453.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$378.16
|
| Rate for Payer: United Healthcare All Other HMO |
$378.16
|
| Rate for Payer: United Healthcare HMO Rider |
$378.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$378.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$867.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: Vantage Medical Group Senior |
$578.61
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.51 |
| Max. Negotiated Rate |
$642.86 |
| Rate for Payer: Blue Shield of California Commercial |
$538.49
|
| Rate for Payer: Blue Shield of California EPN |
$387.23
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cigna of CA HMO |
$529.42
|
| Rate for Payer: Cigna of CA PPO |
$529.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$302.52
|
| Rate for Payer: Galaxy Health WC |
$642.86
|
| Rate for Payer: Global Benefits Group Commercial |
$453.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$288.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.51
|
| Rate for Payer: Multiplan Commercial |
$605.05
|
| Rate for Payer: Networks By Design Commercial |
$378.16
|
| Rate for Payer: Prime Health Services Commercial |
$642.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$285.58
|
| Rate for Payer: United Healthcare All Other HMO |
$278.93
|
| Rate for Payer: United Healthcare HMO Rider |
$272.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.58
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.61
|
| Rate for Payer: Blue Distinction Transplant |
$5.65
|
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$5.50
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO |
$6.59
|
| Rate for Payer: Cigna of CA PPO |
$6.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.01
|
| Rate for Payer: Dignity Health Media |
$8.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.77
|
| Rate for Payer: Galaxy Health WC |
$8.01
|
| Rate for Payer: Global Benefits Group Commercial |
$5.65
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$7.54
|
| Rate for Payer: Networks By Design Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$8.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Other HMO |
$4.71
|
| Rate for Payer: United Healthcare HMO Rider |
$4.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Blue Shield of California Commercial |
$6.71
|
| Rate for Payer: Blue Shield of California EPN |
$4.82
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO |
$6.59
|
| Rate for Payer: Cigna of CA PPO |
$6.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: Galaxy Health WC |
$8.01
|
| Rate for Payer: Global Benefits Group Commercial |
$5.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$7.54
|
| Rate for Payer: Networks By Design Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$13.34 |
| Rate for Payer: Blue Shield of California Commercial |
$11.18
|
| Rate for Payer: Blue Shield of California EPN |
$8.04
|
| Rate for Payer: Cash Price |
$7.07
|
| Rate for Payer: Cigna of CA HMO |
$10.99
|
| Rate for Payer: Cigna of CA PPO |
$10.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.34
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.77
|
| Rate for Payer: Multiplan Commercial |
$12.56
|
| Rate for Payer: Networks By Design Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$13.34
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$13.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$10.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.35
|
| Rate for Payer: Blue Distinction Transplant |
$9.42
|
| Rate for Payer: Blue Shield of California Commercial |
$11.57
|
| Rate for Payer: Blue Shield of California EPN |
$9.17
|
| Rate for Payer: Cash Price |
$7.07
|
| Rate for Payer: Cigna of CA HMO |
$10.99
|
| Rate for Payer: Cigna of CA PPO |
$10.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.34
|
| Rate for Payer: Dignity Health Media |
$13.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.34
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.77
|
| Rate for Payer: Multiplan Commercial |
$12.56
|
| Rate for Payer: Networks By Design Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$13.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.85
|
| Rate for Payer: United Healthcare All Other HMO |
$7.85
|
| Rate for Payer: United Healthcare HMO Rider |
$7.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.34
|
| Rate for Payer: Vantage Medical Group Senior |
$13.34
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
OP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.40 |
| Max. Negotiated Rate |
$337.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$260.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$337.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$218.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$218.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$236.82
|
| Rate for Payer: Blue Distinction Transplant |
$238.49
|
| Rate for Payer: Blue Shield of California Commercial |
$292.95
|
| Rate for Payer: Blue Shield of California EPN |
$232.13
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: Cigna of CA HMO |
$278.24
|
| Rate for Payer: Cigna of CA PPO |
$278.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$337.87
|
| Rate for Payer: Dignity Health Media |
$337.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$159.00
|
| Rate for Payer: Galaxy Health WC |
$337.87
|
| Rate for Payer: Global Benefits Group Commercial |
$238.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$298.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$317.99
|
| Rate for Payer: Networks By Design Commercial |
$258.37
|
| Rate for Payer: Prime Health Services Commercial |
$337.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$238.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$238.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$198.74
|
| Rate for Payer: United Healthcare All Other HMO |
$198.74
|
| Rate for Payer: United Healthcare HMO Rider |
$198.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$198.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$337.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.87
|
| Rate for Payer: Vantage Medical Group Senior |
$337.87
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
IP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$95.40 |
| Max. Negotiated Rate |
$337.87 |
| Rate for Payer: Blue Shield of California Commercial |
$283.01
|
| Rate for Payer: Blue Shield of California EPN |
$203.51
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: Cigna of CA HMO |
$278.24
|
| Rate for Payer: Cigna of CA PPO |
$278.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.00
|
| Rate for Payer: Galaxy Health WC |
$337.87
|
| Rate for Payer: Global Benefits Group Commercial |
$238.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$151.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$95.40
|
| Rate for Payer: Multiplan Commercial |
$317.99
|
| Rate for Payer: Networks By Design Commercial |
$258.37
|
| Rate for Payer: Prime Health Services Commercial |
$337.87
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Distinction Transplant |
$4.32
|
| Rate for Payer: Blue Shield of California Commercial |
$5.31
|
| Rate for Payer: Blue Shield of California EPN |
$4.20
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Media |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.73
|
| Rate for Payer: Multiplan Commercial |
$5.76
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO |
$3.60
|
| Rate for Payer: United Healthcare HMO Rider |
$3.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
