|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$786.79
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.36 |
| Max. Negotiated Rate |
$668.77 |
| Rate for Payer: Adventist Health Commercial |
$157.36
|
| Rate for Payer: Blue Shield of California Commercial |
$398.90
|
| Rate for Payer: Blue Shield of California Commercial |
$605.04
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Cigna of CA HMO |
$550.75
|
| Rate for Payer: Cigna of CA PPO |
$550.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$550.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$314.72
|
| Rate for Payer: EPIC Health Plan Senior |
$314.72
|
| Rate for Payer: Galaxy Health WC |
$668.77
|
| Rate for Payer: Global Benefits Group Commercial |
$472.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$499.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$464.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.83
|
| Rate for Payer: Multiplan Commercial |
$629.43
|
| Rate for Payer: Networks By Design Commercial |
$393.39
|
| Rate for Payer: Prime Health Services Commercial |
$668.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.28
|
| Rate for Payer: United Healthcare All Other HMO |
$287.41
|
| Rate for Payer: United Healthcare HMO Rider |
$281.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$257.67
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna of CA HMO |
$1.88
|
| Rate for Payer: Cigna of CA PPO |
$1.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: EPIC Health Plan Senior |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.28
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$13.35 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$12.07
|
| Rate for Payer: Blue Shield of California Commercial |
$7.96
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Cigna of CA HMO |
$10.99
|
| Rate for Payer: Cigna of CA PPO |
$10.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Senior |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.35
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.26
|
| 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 |
$10.21
|
| Rate for Payer: Prime Health Services Commercial |
$13.35
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.03
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.72
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna of CA HMO |
$1.88
|
| Rate for Payer: Cigna of CA PPO |
$1.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: EPIC Health Plan Senior |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.34
|
| Rate for Payer: United Healthcare HMO Rider |
$1.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.28
|
| Rate for Payer: Vantage Medical Group Senior |
$2.28
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$13.35 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.07
|
| Rate for Payer: Cash Price |
$7.06
|
| 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 |
$13.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Senior |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.35
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.99
|
| Rate for Payer: Multiplan Commercial |
$12.56
|
| Rate for Payer: Networks By Design Commercial |
$10.21
|
| Rate for Payer: Prime Health Services Commercial |
$13.35
|
| 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 |
$13.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Vantage Medical Group Senior |
$13.35
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
OP
|
$455.76
|
|
|
Service Code
|
NDC 6738642201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.15 |
| Max. Negotiated Rate |
$387.40 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$298.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$250.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$341.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$292.46
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna of CA HMO |
$319.03
|
| Rate for Payer: Cigna of CA PPO |
$319.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$387.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$387.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.30
|
| Rate for Payer: EPIC Health Plan Senior |
$182.30
|
| Rate for Payer: Galaxy Health WC |
$387.40
|
| Rate for Payer: Global Benefits Group Commercial |
$273.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$268.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$319.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$319.03
|
| Rate for Payer: Multiplan Commercial |
$364.61
|
| Rate for Payer: Networks By Design Commercial |
$296.24
|
| Rate for Payer: Prime Health Services Commercial |
$387.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$273.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$273.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$227.88
|
| Rate for Payer: United Healthcare All Other HMO |
$227.88
|
| Rate for Payer: United Healthcare HMO Rider |
$227.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$227.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$387.40
|
| Rate for Payer: Vantage Medical Group Senior |
$387.40
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
IP
|
$455.76
|
|
|
Service Code
|
NDC 6738642201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.15 |
| Max. Negotiated Rate |
$387.40 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Blue Shield of California Commercial |
$231.07
|
| Rate for Payer: Blue Shield of California Commercial |
$350.48
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Cigna of CA HMO |
$319.03
|
| Rate for Payer: Cigna of CA PPO |
$319.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.30
|
| Rate for Payer: EPIC Health Plan Senior |
$182.30
|
| Rate for Payer: Galaxy Health WC |
$387.40
|
| Rate for Payer: Global Benefits Group Commercial |
$273.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$268.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.38
|
| Rate for Payer: Multiplan Commercial |
$364.61
|
| Rate for Payer: Networks By Design Commercial |
$296.24
|
| Rate for Payer: Prime Health Services Commercial |
$387.40
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cigna of CA HMO |
$2.91
|
| Rate for Payer: Cigna of CA PPO |
$2.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: EPIC Health Plan Senior |
$1.66
|
| Rate for Payer: Galaxy Health WC |
$3.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$3.54
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cigna of CA HMO |
$2.91
|
| Rate for Payer: Cigna of CA PPO |
$2.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: EPIC Health Plan Senior |
$1.66
|
| Rate for Payer: Galaxy Health WC |
$3.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.91
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$3.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.08
|
| Rate for Payer: United Healthcare All Other HMO |
$2.08
|
| Rate for Payer: United Healthcare HMO Rider |
$2.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.54
|
| Rate for Payer: Vantage Medical Group Senior |
$3.54
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.03
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 6021915231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 6021915231
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.90
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$2.37
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.53
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| 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 |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994080348
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.74
|
| Rate for Payer: Blue Shield of California Commercial |
$60.50
|
| Rate for Payer: Blue Shield of California Commercial |
$39.92
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$80.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$66.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$66.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Blue Shield of California Commercial |
$72.92
|
| Rate for Payer: Blue Shield of California Commercial |
$48.08
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$66.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.76
|
| Rate for Payer: Multiplan Commercial |
$75.86
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR [7820]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121082016
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
