|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [7994]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA HMO |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.83
|
| Rate for Payer: Cigna of CA PPO |
$0.60
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$0.73
|
| Rate for Payer: Galaxy Health WC |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
IP
|
$112.32
|
|
|
Service Code
|
NDC 0078087601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$95.47 |
| Rate for Payer: Adventist Health Commercial |
$22.46
|
| Rate for Payer: Blue Shield of California Commercial |
$56.95
|
| Rate for Payer: Blue Shield of California Commercial |
$86.37
|
| Rate for Payer: Cash Price |
$50.54
|
| Rate for Payer: Cigna of CA HMO |
$78.62
|
| Rate for Payer: Cigna of CA PPO |
$78.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$78.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.93
|
| Rate for Payer: EPIC Health Plan Senior |
$44.93
|
| Rate for Payer: Galaxy Health WC |
$95.47
|
| Rate for Payer: Global Benefits Group Commercial |
$67.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$71.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.96
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Networks By Design Commercial |
$73.01
|
| Rate for Payer: Prime Health Services Commercial |
$95.47
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
OP
|
$112.32
|
|
|
Service Code
|
NDC 0078087601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$95.47 |
| Rate for Payer: Adventist Health Commercial |
$22.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$73.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.08
|
| Rate for Payer: Cash Price |
$50.54
|
| Rate for Payer: Cigna of CA HMO |
$78.62
|
| Rate for Payer: Cigna of CA PPO |
$78.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$78.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.93
|
| Rate for Payer: EPIC Health Plan Senior |
$44.93
|
| Rate for Payer: Galaxy Health WC |
$95.47
|
| Rate for Payer: Global Benefits Group Commercial |
$67.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$71.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$40.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.62
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Networks By Design Commercial |
$73.01
|
| Rate for Payer: Prime Health Services Commercial |
$95.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$67.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$67.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.16
|
| Rate for Payer: United Healthcare All Other HMO |
$56.16
|
| Rate for Payer: United Healthcare HMO Rider |
$56.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$56.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.47
|
| Rate for Payer: Vantage Medical Group Senior |
$95.47
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$7.97
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.93
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$95.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$95.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [108062]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Blue Shield of California Commercial |
$122.54
|
| Rate for Payer: Blue Shield of California Commercial |
$80.79
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.74
|
| Rate for Payer: EPIC Health Plan Senior |
$63.74
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
OP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.45
|
| Rate for Payer: Blue Shield of California Commercial |
$7.97
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.93
|
| Rate for Payer: EPIC Health Plan Senior |
$5.95
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.25
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$95.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$95.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [108061]
|
Facility
|
IP
|
$159.35
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$135.45 |
| Rate for Payer: Adventist Health Commercial |
$31.87
|
| Rate for Payer: Blue Shield of California Commercial |
$122.54
|
| Rate for Payer: Blue Shield of California Commercial |
$80.79
|
| Rate for Payer: Cash Price |
$71.71
|
| Rate for Payer: Cigna of CA HMO |
$111.55
|
| Rate for Payer: Cigna of CA PPO |
$111.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$111.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.74
|
| Rate for Payer: EPIC Health Plan Senior |
$63.74
|
| Rate for Payer: Galaxy Health WC |
$135.45
|
| Rate for Payer: Global Benefits Group Commercial |
$95.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$101.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.24
|
| Rate for Payer: Multiplan Commercial |
$127.48
|
| Rate for Payer: Networks By Design Commercial |
$79.67
|
| Rate for Payer: Prime Health Services Commercial |
$135.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.80
|
| Rate for Payer: United Healthcare All Other HMO |
$58.21
|
| Rate for Payer: United Healthcare HMO Rider |
$56.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.19
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$59.57
|
| Rate for Payer: Blue Shield of California Commercial |
$90.36
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOCILIZUMAB-AAZG 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION [241038]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.58
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.70
|
| Rate for Payer: EPIC Health Plan Senior |
$4.47
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.44
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Vantage Medical Group Senior |
$4.47
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.58
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.70
|
| Rate for Payer: EPIC Health Plan Senior |
$4.47
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.44
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Vantage Medical Group Senior |
$4.47
|
|
|
TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [241039]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$59.57
|
| Rate for Payer: Blue Shield of California Commercial |
$90.36
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
IP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Blue Shield of California Commercial |
$59.57
|
| Rate for Payer: Blue Shield of California Commercial |
$90.36
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.00
|
| Rate for Payer: EPIC Health Plan Senior |
$47.00
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
|
|
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [241037]
|
Facility
|
OP
|
$117.50
|
|
|
Service Code
|
HCPCS Q5135
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$99.88 |
| Rate for Payer: Adventist Health Commercial |
$23.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.58
|
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cigna of CA HMO |
$82.25
|
| Rate for Payer: Cigna of CA PPO |
$82.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.70
|
| Rate for Payer: EPIC Health Plan Senior |
$4.47
|
| Rate for Payer: Galaxy Health WC |
$99.88
|
| Rate for Payer: Global Benefits Group Commercial |
$70.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.44
|
| Rate for Payer: Multiplan Commercial |
$94.00
|
| Rate for Payer: Networks By Design Commercial |
$58.75
|
| Rate for Payer: Prime Health Services Commercial |
$99.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.10
|
| Rate for Payer: United Healthcare All Other HMO |
$42.92
|
| Rate for Payer: United Healthcare HMO Rider |
$41.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: Vantage Medical Group Senior |
$4.47
|
|
|
TOFERSEN 100 MG/15 ML (6.7 MG/ML) INTRATHECAL SOLUTION [237803]
|
Facility
|
IP
|
$1,243.96
|
|
|
Service Code
|
HCPCS J1304
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.79 |
| Max. Negotiated Rate |
$1,057.37 |
| Rate for Payer: Adventist Health Commercial |
$248.79
|
| Rate for Payer: Blue Shield of California Commercial |
$630.69
|
| Rate for Payer: Blue Shield of California Commercial |
$956.61
|
| Rate for Payer: Cash Price |
$559.78
|
| Rate for Payer: Cigna of CA HMO |
$870.77
|
| Rate for Payer: Cigna of CA PPO |
$870.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$870.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$497.58
|
| Rate for Payer: EPIC Health Plan Senior |
$497.58
|
| Rate for Payer: Galaxy Health WC |
$1,057.37
|
| Rate for Payer: Global Benefits Group Commercial |
$746.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$789.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$733.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.55
|
| Rate for Payer: Multiplan Commercial |
$995.17
|
| Rate for Payer: Networks By Design Commercial |
$621.98
|
| Rate for Payer: Prime Health Services Commercial |
$1,057.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$466.86
|
| Rate for Payer: United Healthcare All Other HMO |
$454.42
|
| Rate for Payer: United Healthcare HMO Rider |
$444.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$407.40
|
|
|
TOFERSEN 100 MG/15 ML (6.7 MG/ML) INTRATHECAL SOLUTION [237803]
|
Facility
|
OP
|
$1,243.96
|
|
|
Service Code
|
HCPCS J1304
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.82 |
| Max. Negotiated Rate |
$1,057.37 |
| Rate for Payer: Adventist Health Commercial |
$248.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$976.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$206.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$181.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$181.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$363.47
|
| Rate for Payer: Blue Shield of California Commercial |
$175.88
|
| Rate for Payer: Cash Price |
$559.78
|
| Rate for Payer: Cash Price |
$559.78
|
| Rate for Payer: Cigna of CA HMO |
$870.77
|
| Rate for Payer: Cigna of CA PPO |
$870.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$206.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$181.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$181.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$870.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$271.95
|
| Rate for Payer: EPIC Health Plan Senior |
$181.30
|
| Rate for Payer: Galaxy Health WC |
$1,057.37
|
| Rate for Payer: Global Benefits Group Commercial |
$746.38
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$270.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$164.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$164.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$789.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$304.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$230.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$298.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$207.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$220.86
|
| Rate for Payer: Multiplan Commercial |
$995.17
|
| Rate for Payer: Networks By Design Commercial |
$621.98
|
| Rate for Payer: Prime Health Services Commercial |
$1,057.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$746.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$746.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$466.86
|
| Rate for Payer: United Healthcare All Other HMO |
$454.42
|
| Rate for Payer: United Healthcare HMO Rider |
$444.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$407.40
|
| Rate for Payer: Upland Medical Group Pediatric |
$164.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$206.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$181.30
|
| Rate for Payer: Vantage Medical Group Senior |
$181.30
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 5167220202
|
| 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
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 2438503203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 5167220202
|
| 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
|
|
|
TOLNAFTATE 1 % TOPICAL CREAM [8020]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 2438503203
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$3.18
|
|
|
Service Code
|
NDC 0093001006
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.04
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: EPIC Health Plan Senior |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.59
|
| Rate for Payer: United Healthcare All Other HMO |
$1.59
|
| Rate for Payer: United Healthcare HMO Rider |
$1.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.70
|
| Rate for Payer: Vantage Medical Group Senior |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 3334209709
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 0093001006
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Cigna of CA HMO |
$2.23
|
| Rate for Payer: Cigna of CA PPO |
$2.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: EPIC Health Plan Senior |
$1.27
|
| Rate for Payer: Galaxy Health WC |
$2.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.54
|
| Rate for Payer: Networks By Design Commercial |
$2.07
|
| Rate for Payer: Prime Health Services Commercial |
$2.70
|
|
|
TOLTERODINE 1 MG TABLET [22782]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 3334209709
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 3334209809
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
TOLTERODINE 2 MG TABLET [22783]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 3172280660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
