|
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: Dignity Health Medi-Cal |
$72.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$415.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$82.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$72.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$166.08
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant Other |
$841.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.28
|
| Rate for Payer: Heritage Provider Network Transplant |
$108.28
|
| Rate for Payer: IEHP Medi-Cal |
$106.96
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$106.96
|
| Rate for Payer: 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 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1,387.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$897.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$897.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$972.39
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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
|
|
|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$22.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.65
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: IEHP Medi-Cal |
$28.58
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$28.58
|
| Rate for Payer: 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
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: Galaxy Health WC |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.15
|
| 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: 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
|
|
|
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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$41.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.38
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$45.70
|
| 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
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: AlphaCare Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.97
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$36.22
|
| 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
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: BCBS Transplant Transplant |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Media |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: BCBS Transplant Transplant |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Media |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
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 |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: BCBS Transplant Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Media |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
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 |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
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 |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.59
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: Networks By Design Commercial |
$0.45
|
| Rate for Payer: Prime Health Services Commercial |
$0.59
|
|
|
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 |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
