|
TRANEXAMIC ACID 650 MG TABLET [104576]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 62559-265-30
|
| Hospital Charge Code |
ERX104576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
TRANEXAMIC ACID 650 MG TABLET [104576]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 62559-265-30
|
| Hospital Charge Code |
ERX104576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.91
|
| Rate for Payer: Blue Distinction Transplant |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$2.24
|
| Rate for Payer: Cigna of CA PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Media |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.56
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO |
$1.60
|
| Rate for Payer: United Healthcare HMO Rider |
$1.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
TRANEXAMIC ACID ORAL SOLUTION (IV FORM) 5% (50 MG/ML) [40820838]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 9940-8208-38
|
| Hospital Charge Code |
NDG40820838
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.67
|
| Rate for Payer: Cigna of CA PPO |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Networks By Design Commercial |
$0.62
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
|
|
TRANEXAMIC ACID ORAL SOLUTION (IV FORM) 5% (50 MG/ML) [40820838]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 9940-8208-38
|
| Hospital Charge Code |
NDG40820838
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.57
|
| Rate for Payer: Blue Distinction Transplant |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.67
|
| Rate for Payer: Cigna of CA PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.82
|
| Rate for Payer: Dignity Health Media |
$0.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.82
|
| Rate for Payer: Global Benefits Group Commercial |
$0.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Networks By Design Commercial |
$0.62
|
| Rate for Payer: Prime Health Services Commercial |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO |
$0.48
|
| Rate for Payer: United Healthcare HMO Rider |
$0.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Vantage Medical Group Senior |
$0.82
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$10,261.24
|
|
|
Service Code
|
APR-DRG 0471
|
| Min. Negotiated Rate |
$7,871.45 |
| Max. Negotiated Rate |
$10,261.24 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,871.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,261.24
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$23,929.30
|
|
|
Service Code
|
APR-DRG 0474
|
| Min. Negotiated Rate |
$18,356.29 |
| Max. Negotiated Rate |
$23,929.30 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,356.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,929.30
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$11,711.92
|
|
|
Service Code
|
APR-DRG 0472
|
| Min. Negotiated Rate |
$8,984.28 |
| Max. Negotiated Rate |
$11,711.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,984.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,711.92
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$14,709.08
|
|
|
Service Code
|
APR-DRG 0473
|
| Min. Negotiated Rate |
$11,283.41 |
| Max. Negotiated Rate |
$14,709.08 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,283.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,709.08
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$11,309.35
|
|
|
Service Code
|
APR-DRG 4821
|
| Min. Negotiated Rate |
$8,675.46 |
| Max. Negotiated Rate |
$11,309.35 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,675.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,309.35
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$13,831.22
|
|
|
Service Code
|
APR-DRG 4822
|
| Min. Negotiated Rate |
$10,610.00 |
| Max. Negotiated Rate |
$13,831.22 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,610.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,831.22
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$41,858.98
|
|
|
Service Code
|
APR-DRG 4824
|
| Min. Negotiated Rate |
$32,110.24 |
| Max. Negotiated Rate |
$41,858.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32,110.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,858.98
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$25,154.76
|
|
|
Service Code
|
APR-DRG 4823
|
| Min. Negotiated Rate |
$19,296.35 |
| Max. Negotiated Rate |
$25,154.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,296.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25,154.76
|
|
|
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 64486
|
| Min. Negotiated Rate |
$4,984.00 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
|
IP
|
$1,870.10
|
|
|
Service Code
|
CPT J9355
|
| Hospital Charge Code |
ERX216113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$448.82 |
| Max. Negotiated Rate |
$1,589.58 |
| Rate for Payer: Blue Shield of California Commercial |
$1,331.51
|
| Rate for Payer: Blue Shield of California EPN |
$957.49
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cigna of CA HMO |
$1,309.07
|
| Rate for Payer: Cigna of CA PPO |
$1,309.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$748.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$748.04
|
| Rate for Payer: Galaxy Health WC |
$1,589.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1,122.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,247.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$712.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$448.82
|
| Rate for Payer: Multiplan Commercial |
$1,496.08
|
| Rate for Payer: Networks By Design Commercial |
$935.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,589.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$706.15
|
| Rate for Payer: United Healthcare All Other HMO |
$689.69
|
| Rate for Payer: United Healthcare HMO Rider |
$674.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$617.13
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
|
OP
|
$1,870.10
|
|
|
Service Code
|
CPT J9355
|
| Hospital Charge Code |
ERX216113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.46 |
| Max. Negotiated Rate |
$1,589.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$506.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$100.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.65
|
| Rate for Payer: Blue Distinction Transplant |
$1,122.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1,378.26
|
| Rate for Payer: Blue Shield of California EPN |
$124.67
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cigna of CA HMO |
$1,309.07
|
| Rate for Payer: Cigna of CA PPO |
$1,309.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.70
|
| Rate for Payer: Dignity Health Media |
$80.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$80.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$80.46
|
| Rate for Payer: Galaxy Health WC |
$1,589.58
|
| Rate for Payer: Global Benefits Group Commercial |
$1,122.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,402.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.96
|
| Rate for Payer: Heritage Provider Network Transplant |
$131.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$130.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$130.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$80.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,247.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$161.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$80.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$448.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$101.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107.82
|
| Rate for Payer: Multiplan Commercial |
$1,496.08
|
| Rate for Payer: Networks By Design Commercial |
$935.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,589.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,122.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,122.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$935.05
|
| Rate for Payer: United Healthcare All Other HMO |
$935.05
|
| Rate for Payer: United Healthcare HMO Rider |
$935.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$935.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$120.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: Vantage Medical Group Senior |
$80.46
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
|
IP
|
$1,122.06
|
|
|
Service Code
|
CPT J9356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.29 |
| Max. Negotiated Rate |
$953.75 |
| Rate for Payer: Blue Shield of California Commercial |
$798.91
|
| Rate for Payer: Blue Shield of California EPN |
$574.49
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cigna of CA HMO |
$785.44
|
| Rate for Payer: Cigna of CA PPO |
$785.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$448.82
|
| Rate for Payer: Galaxy Health WC |
$953.75
|
| Rate for Payer: Global Benefits Group Commercial |
$673.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$427.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.29
|
| Rate for Payer: Multiplan Commercial |
$897.65
|
| Rate for Payer: Networks By Design Commercial |
$561.03
|
| Rate for Payer: Prime Health Services Commercial |
$953.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$423.69
|
| Rate for Payer: United Healthcare All Other HMO |
$413.82
|
| Rate for Payer: United Healthcare HMO Rider |
$404.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$370.28
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
|
OP
|
$1,122.06
|
|
|
Service Code
|
CPT J9356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.02 |
| Max. Negotiated Rate |
$953.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$415.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$82.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$166.08
|
| Rate for Payer: Blue Distinction Transplant |
$673.24
|
| Rate for Payer: Blue Shield of California Commercial |
$826.96
|
| Rate for Payer: Blue Shield of California EPN |
$93.50
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cigna of CA HMO |
$785.44
|
| Rate for Payer: Cigna of CA PPO |
$785.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.53
|
| Rate for Payer: Dignity Health Media |
$72.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.13
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$66.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$66.02
|
| Rate for Payer: Galaxy Health WC |
$953.75
|
| Rate for Payer: Global Benefits Group Commercial |
$673.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$841.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.28
|
| Rate for Payer: Heritage Provider Network Transplant |
$108.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$106.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$106.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$66.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$748.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$133.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$269.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$83.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$88.47
|
| Rate for Payer: Multiplan Commercial |
$897.65
|
| Rate for Payer: Networks By Design Commercial |
$561.03
|
| Rate for Payer: Prime Health Services Commercial |
$953.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$673.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$673.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$561.03
|
| Rate for Payer: United Healthcare All Other HMO |
$561.03
|
| Rate for Payer: United Healthcare HMO Rider |
$561.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$561.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: Vantage Medical Group Senior |
$72.62
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
|
OP
|
$1,632.08
|
|
|
Service Code
|
NDC 55513-141-01
|
| Hospital Charge Code |
ERX226189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$391.70 |
| Max. Negotiated Rate |
$1,387.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,070.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,387.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$897.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$897.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$972.39
|
| Rate for Payer: Blue Distinction Transplant |
$979.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,202.84
|
| Rate for Payer: Blue Shield of California EPN |
$953.13
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Cigna of CA HMO |
$1,142.46
|
| Rate for Payer: Cigna of CA PPO |
$1,142.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,387.27
|
| Rate for Payer: Dignity Health Media |
$1,387.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,387.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$652.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$652.83
|
| Rate for Payer: Galaxy Health WC |
$1,387.27
|
| Rate for Payer: Global Benefits Group Commercial |
$979.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,224.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,088.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$621.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.70
|
| Rate for Payer: Multiplan Commercial |
$1,305.66
|
| Rate for Payer: Networks By Design Commercial |
$816.04
|
| Rate for Payer: Prime Health Services Commercial |
$1,387.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$979.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$979.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$816.04
|
| Rate for Payer: United Healthcare All Other HMO |
$816.04
|
| Rate for Payer: United Healthcare HMO Rider |
$816.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$816.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,387.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,387.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1,387.27
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
|
IP
|
$1,632.08
|
|
|
Service Code
|
NDC 55513-141-01
|
| Hospital Charge Code |
ERX226189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$391.70 |
| Max. Negotiated Rate |
$1,387.27 |
| Rate for Payer: Blue Shield of California Commercial |
$1,162.04
|
| Rate for Payer: Blue Shield of California EPN |
$835.62
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Cigna of CA HMO |
$1,142.46
|
| Rate for Payer: Cigna of CA PPO |
$1,142.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$652.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$652.83
|
| Rate for Payer: Galaxy Health WC |
$1,387.27
|
| Rate for Payer: Global Benefits Group Commercial |
$979.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,088.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$621.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$391.70
|
| Rate for Payer: Multiplan Commercial |
$1,305.66
|
| Rate for Payer: Networks By Design Commercial |
$816.04
|
| Rate for Payer: Prime Health Services Commercial |
$1,387.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$616.27
|
| Rate for Payer: United Healthcare All Other HMO |
$601.91
|
| Rate for Payer: United Healthcare HMO Rider |
$588.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$538.59
|
|
|
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 |
$1,096.76 |
| Max. Negotiated Rate |
$3,884.35 |
| Rate for Payer: Blue Shield of California Commercial |
$3,253.71
|
| Rate for Payer: Blue Shield of California EPN |
$2,339.75
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cigna of CA HMO |
$3,198.87
|
| Rate for Payer: Cigna of CA PPO |
$3,198.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,827.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,827.93
|
| Rate for Payer: Galaxy Health WC |
$3,884.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2,741.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,048.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,741.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,096.76
|
| Rate for Payer: Multiplan Commercial |
$3,655.86
|
| Rate for Payer: Networks By Design Commercial |
$2,284.91
|
| Rate for Payer: Prime Health Services Commercial |
$3,884.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,725.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1,685.35
|
| Rate for Payer: United Healthcare HMO Rider |
$1,648.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,508.04
|
|
|
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 |
$17.64 |
| Max. Negotiated Rate |
$3,884.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$84.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.65
|
| Rate for Payer: Blue Distinction Transplant |
$2,741.89
|
| Rate for Payer: Blue Shield of California Commercial |
$3,367.96
|
| Rate for Payer: Blue Shield of California EPN |
$2,668.77
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cigna of CA HMO |
$3,198.87
|
| Rate for Payer: Cigna of CA PPO |
$3,198.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.05
|
| Rate for Payer: Dignity Health Media |
$19.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$17.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$17.64
|
| Rate for Payer: Galaxy Health WC |
$3,884.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2,741.89
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,427.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.93
|
| Rate for Payer: Heritage Provider Network Transplant |
$28.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$28.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,048.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,096.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.64
|
| Rate for Payer: Multiplan Commercial |
$3,655.86
|
| Rate for Payer: Networks By Design Commercial |
$2,284.91
|
| Rate for Payer: Prime Health Services Commercial |
$3,884.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,741.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,741.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,284.91
|
| Rate for Payer: United Healthcare All Other HMO |
$2,284.91
|
| Rate for Payer: United Healthcare HMO Rider |
$2,284.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,284.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.40
|
| Rate for Payer: Vantage Medical Group Senior |
$19.40
|
|
|
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 |
$18.28 |
| Max. Negotiated Rate |
$64.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$49.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.38
|
| Rate for Payer: Blue Distinction Transplant |
$45.70
|
| Rate for Payer: Blue Shield of California Commercial |
$56.14
|
| Rate for Payer: Blue Shield of California EPN |
$44.48
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Cigna of CA HMO |
$53.32
|
| Rate for Payer: Cigna of CA PPO |
$53.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.74
|
| Rate for Payer: Dignity Health Media |
$64.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$30.47
|
| Rate for Payer: Galaxy Health WC |
$64.74
|
| Rate for Payer: Global Benefits Group Commercial |
$45.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$57.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$50.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.28
|
| Rate for Payer: Multiplan Commercial |
$60.94
|
| Rate for Payer: Networks By Design Commercial |
$49.51
|
| Rate for Payer: Prime Health Services Commercial |
$64.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$45.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$45.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.08
|
| Rate for Payer: United Healthcare All Other HMO |
$38.08
|
| Rate for Payer: United Healthcare HMO Rider |
$38.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.74
|
| Rate for Payer: Vantage Medical Group Senior |
$64.74
|
|
|
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 |
$18.28 |
| Max. Negotiated Rate |
$64.74 |
| Rate for Payer: Blue Shield of California Commercial |
$54.23
|
| Rate for Payer: Blue Shield of California EPN |
$39.00
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Cigna of CA HMO |
$53.32
|
| Rate for Payer: Cigna of CA PPO |
$53.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.47
|
| Rate for Payer: Galaxy Health WC |
$64.74
|
| Rate for Payer: Global Benefits Group Commercial |
$45.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$50.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.28
|
| Rate for Payer: Multiplan Commercial |
$60.94
|
| Rate for Payer: Networks By Design Commercial |
$49.51
|
| Rate for Payer: Prime Health Services Commercial |
$64.74
|
|
|
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 |
$14.49 |
| Max. Negotiated Rate |
$51.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$39.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.97
|
| Rate for Payer: Blue Distinction Transplant |
$36.22
|
| Rate for Payer: Blue Shield of California Commercial |
$44.49
|
| Rate for Payer: Blue Shield of California EPN |
$35.26
|
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: Cigna of CA HMO |
$42.26
|
| Rate for Payer: Cigna of CA PPO |
$42.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.31
|
| Rate for Payer: Dignity Health Media |
$51.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.15
|
| Rate for Payer: Galaxy Health WC |
$51.31
|
| Rate for Payer: Global Benefits Group Commercial |
$36.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$45.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.49
|
| Rate for Payer: Multiplan Commercial |
$48.30
|
| Rate for Payer: Networks By Design Commercial |
$39.24
|
| Rate for Payer: Prime Health Services Commercial |
$51.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.18
|
| Rate for Payer: United Healthcare All Other HMO |
$30.18
|
| Rate for Payer: United Healthcare HMO Rider |
$30.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.31
|
| Rate for Payer: Vantage Medical Group Senior |
$51.31
|
|
|
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 |
$14.49 |
| Max. Negotiated Rate |
$51.31 |
| Rate for Payer: Blue Shield of California Commercial |
$42.98
|
| Rate for Payer: Blue Shield of California EPN |
$30.91
|
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: Cigna of CA HMO |
$42.26
|
| Rate for Payer: Cigna of CA PPO |
$42.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.15
|
| Rate for Payer: Galaxy Health WC |
$51.31
|
| Rate for Payer: Global Benefits Group Commercial |
$36.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.49
|
| Rate for Payer: Multiplan Commercial |
$48.30
|
| Rate for Payer: Networks By Design Commercial |
$39.24
|
| Rate for Payer: Prime Health Services Commercial |
$51.31
|
|
