|
TRAZODONE ORAL SUSPENSION COMPOUND 10 MG/ML [4080353]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 9994080353
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 67228
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$504.12 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,061.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$778.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$707.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,061.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$778.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$707.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,167.19
|
| Rate for Payer: EPIC Health Plan Senior |
$778.13
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,160.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$504.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$707.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$570.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$990.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$891.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$947.90
|
| Rate for Payer: Multiplan WC |
$1,110.63
|
| Rate for Payer: Prime Health Services WC |
$1,099.30
|
| Rate for Payer: United Healthcare All Other HMO |
$4,460.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,591.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,374.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$707.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,061.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$778.13
|
| Rate for Payer: Vantage Medical Group Senior |
$707.39
|
|
|
TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 59812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$283.33 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,869.74
|
| Rate for Payer: EPIC Health Plan Senior |
$4,579.83
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,828.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$283.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$320.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,828.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,245.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: Prime Health Services WC |
$6,371.18
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,163.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 59820
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$665.55 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,869.74
|
| Rate for Payer: EPIC Health Plan Senior |
$4,579.83
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,828.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$665.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$752.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,828.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,245.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: Prime Health Services WC |
$6,371.18
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,163.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 59820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$665.55 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,869.74
|
| Rate for Payer: EPIC Health Plan Senior |
$4,579.83
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,828.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$665.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$752.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,828.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,245.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: Prime Health Services WC |
$6,371.18
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,163.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 59821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$283.33 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,869.74
|
| Rate for Payer: EPIC Health Plan Senior |
$4,579.83
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,828.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$283.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$320.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,828.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,245.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: Prime Health Services WC |
$6,371.18
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,163.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE OR MULTIPLE PINNING, IN SITU
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27176
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$275.20 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,323.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,943.76
|
| Rate for Payer: EPIC Health Plan Senior |
$4,629.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,901.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$275.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$311.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,891.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,302.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,639.18
|
| Rate for Payer: United Healthcare All Other HMO |
$28,817.00
|
| Rate for Payer: United Healthcare HMO Rider |
$18,075.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,561.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,208.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [236035]
|
Facility
|
IP
|
$3,393.74
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$678.75 |
| Max. Negotiated Rate |
$2,884.68 |
| Rate for Payer: Adventist Health Commercial |
$678.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1,720.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2,609.79
|
| Rate for Payer: Cash Price |
$1,527.18
|
| Rate for Payer: Cigna of CA HMO |
$2,375.62
|
| Rate for Payer: Cigna of CA PPO |
$2,375.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,375.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,357.50
|
| Rate for Payer: EPIC Health Plan Senior |
$1,357.50
|
| Rate for Payer: Galaxy Health WC |
$2,884.68
|
| Rate for Payer: Global Benefits Group Commercial |
$2,036.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,155.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,002.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$814.50
|
| Rate for Payer: Multiplan Commercial |
$2,714.99
|
| Rate for Payer: Networks By Design Commercial |
$1,696.87
|
| Rate for Payer: Prime Health Services Commercial |
$2,884.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,273.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,239.73
|
| Rate for Payer: United Healthcare HMO Rider |
$1,212.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,111.45
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [236035]
|
Facility
|
OP
|
$3,393.74
|
|
|
Service Code
|
HCPCS J9347
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$2,884.68 |
| Rate for Payer: Adventist Health Commercial |
$678.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$869.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$183.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$161.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$161.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$332.18
|
| Rate for Payer: Blue Shield of California Commercial |
$159.12
|
| Rate for Payer: Cash Price |
$1,527.18
|
| Rate for Payer: Cash Price |
$1,527.18
|
| Rate for Payer: Cigna of CA HMO |
$2,375.62
|
| Rate for Payer: Cigna of CA PPO |
$2,375.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$183.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$161.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$161.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,375.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$242.37
|
| Rate for Payer: EPIC Health Plan Senior |
$161.58
|
| Rate for Payer: Galaxy Health WC |
$2,884.68
|
| Rate for Payer: Global Benefits Group Commercial |
$2,036.24
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$240.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$146.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$146.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,155.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$271.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$205.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$814.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$185.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.83
|
| Rate for Payer: Multiplan Commercial |
$2,714.99
|
| Rate for Payer: Networks By Design Commercial |
$1,696.87
|
| Rate for Payer: Prime Health Services Commercial |
$2,884.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,036.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,036.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,273.67
|
| Rate for Payer: United Healthcare All Other HMO |
$1,239.73
|
| Rate for Payer: United Healthcare HMO Rider |
$1,212.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,111.45
|
| Rate for Payer: Upland Medical Group Pediatric |
$146.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$183.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$161.58
|
| Rate for Payer: Vantage Medical Group Senior |
$161.58
|
|
|
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION [120688]
|
Facility
|
IP
|
$353.43
|
|
|
Service Code
|
NDC 6630220603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.69 |
| Max. Negotiated Rate |
$300.42 |
| Rate for Payer: Adventist Health Commercial |
$70.69
|
| Rate for Payer: Blue Shield of California Commercial |
$179.19
|
| Rate for Payer: Blue Shield of California Commercial |
$271.79
|
| Rate for Payer: Cash Price |
$159.04
|
| Rate for Payer: Cigna of CA HMO |
$247.40
|
| Rate for Payer: Cigna of CA PPO |
$247.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$247.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.37
|
| Rate for Payer: EPIC Health Plan Senior |
$141.37
|
| Rate for Payer: Galaxy Health WC |
$300.42
|
| Rate for Payer: Global Benefits Group Commercial |
$212.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$224.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$208.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.82
|
| Rate for Payer: Multiplan Commercial |
$282.74
|
| Rate for Payer: Networks By Design Commercial |
$229.73
|
| Rate for Payer: Prime Health Services Commercial |
$300.42
|
|
|
TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) SOLUTION FOR NEBULIZATION [120688]
|
Facility
|
OP
|
$353.43
|
|
|
Service Code
|
NDC 6630220603
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.69 |
| Max. Negotiated Rate |
$300.42 |
| Rate for Payer: Adventist Health Commercial |
$70.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$231.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$300.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$194.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$265.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$226.80
|
| Rate for Payer: Cash Price |
$159.04
|
| Rate for Payer: Cigna of CA HMO |
$247.40
|
| Rate for Payer: Cigna of CA PPO |
$247.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$300.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$300.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$300.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$247.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.37
|
| Rate for Payer: EPIC Health Plan Senior |
$141.37
|
| Rate for Payer: Galaxy Health WC |
$300.42
|
| Rate for Payer: Global Benefits Group Commercial |
$212.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$224.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$128.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$208.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$247.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$247.40
|
| Rate for Payer: Multiplan Commercial |
$282.74
|
| Rate for Payer: Networks By Design Commercial |
$229.73
|
| Rate for Payer: Prime Health Services Commercial |
$300.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$212.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$212.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$176.72
|
| Rate for Payer: United Healthcare All Other HMO |
$176.72
|
| Rate for Payer: United Healthcare HMO Rider |
$176.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$300.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$300.42
|
| Rate for Payer: Vantage Medical Group Senior |
$300.42
|
|
|
TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]
|
Facility
|
IP
|
$9.17
|
|
|
Service Code
|
NDC 6630230001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cigna of CA HMO |
$6.42
|
| Rate for Payer: Cigna of CA PPO |
$6.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.67
|
| Rate for Payer: EPIC Health Plan Senior |
$3.67
|
| Rate for Payer: Galaxy Health WC |
$7.79
|
| Rate for Payer: Global Benefits Group Commercial |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Networks By Design Commercial |
$5.96
|
| Rate for Payer: Prime Health Services Commercial |
$7.79
|
|
|
TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]
|
Facility
|
OP
|
$9.17
|
|
|
Service Code
|
NDC 6630230002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.88
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cigna of CA HMO |
$6.42
|
| Rate for Payer: Cigna of CA PPO |
$6.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.67
|
| Rate for Payer: EPIC Health Plan Senior |
$3.67
|
| Rate for Payer: Galaxy Health WC |
$7.79
|
| Rate for Payer: Global Benefits Group Commercial |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.42
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Networks By Design Commercial |
$5.96
|
| Rate for Payer: Prime Health Services Commercial |
$7.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Other HMO |
$4.58
|
| Rate for Payer: United Healthcare HMO Rider |
$4.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.79
|
| Rate for Payer: Vantage Medical Group Senior |
$7.79
|
|
|
TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]
|
Facility
|
OP
|
$9.17
|
|
|
Service Code
|
NDC 6630230001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.88
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cigna of CA HMO |
$6.42
|
| Rate for Payer: Cigna of CA PPO |
$6.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.67
|
| Rate for Payer: EPIC Health Plan Senior |
$3.67
|
| Rate for Payer: Galaxy Health WC |
$7.79
|
| Rate for Payer: Global Benefits Group Commercial |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.42
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Networks By Design Commercial |
$5.96
|
| Rate for Payer: Prime Health Services Commercial |
$7.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.58
|
| Rate for Payer: United Healthcare All Other HMO |
$4.58
|
| Rate for Payer: United Healthcare HMO Rider |
$4.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.79
|
| Rate for Payer: Vantage Medical Group Senior |
$7.79
|
|
|
TREPROSTINIL DIOLAMINE ER 0.125 MG TABLET,EXTENDED RELEASE [205150]
|
Facility
|
IP
|
$9.17
|
|
|
Service Code
|
NDC 6630230002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Adventist Health Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cigna of CA HMO |
$6.42
|
| Rate for Payer: Cigna of CA PPO |
$6.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.67
|
| Rate for Payer: EPIC Health Plan Senior |
$3.67
|
| Rate for Payer: Galaxy Health WC |
$7.79
|
| Rate for Payer: Global Benefits Group Commercial |
$5.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.20
|
| Rate for Payer: Multiplan Commercial |
$7.34
|
| Rate for Payer: Networks By Design Commercial |
$5.96
|
| Rate for Payer: Prime Health Services Commercial |
$7.79
|
|
|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
OP
|
$73.33
|
|
|
Service Code
|
NDC 6630231002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$62.33 |
| Rate for Payer: Adventist Health Commercial |
$14.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$48.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.06
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna of CA HMO |
$51.33
|
| Rate for Payer: Cigna of CA PPO |
$51.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$62.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$51.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.33
|
| Rate for Payer: EPIC Health Plan Senior |
$29.33
|
| Rate for Payer: Galaxy Health WC |
$62.33
|
| Rate for Payer: Global Benefits Group Commercial |
$44.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$46.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$51.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.33
|
| Rate for Payer: Multiplan Commercial |
$58.66
|
| Rate for Payer: Networks By Design Commercial |
$47.66
|
| Rate for Payer: Prime Health Services Commercial |
$62.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$44.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$44.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.66
|
| Rate for Payer: United Healthcare All Other HMO |
$36.66
|
| Rate for Payer: United Healthcare HMO Rider |
$36.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.33
|
| Rate for Payer: Vantage Medical Group Senior |
$62.33
|
|
|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
IP
|
$73.33
|
|
|
Service Code
|
NDC 6630231001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$62.33 |
| Rate for Payer: Adventist Health Commercial |
$14.67
|
| Rate for Payer: Blue Shield of California Commercial |
$37.18
|
| Rate for Payer: Blue Shield of California Commercial |
$56.39
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna of CA HMO |
$51.33
|
| Rate for Payer: Cigna of CA PPO |
$51.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$51.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.33
|
| Rate for Payer: EPIC Health Plan Senior |
$29.33
|
| Rate for Payer: Galaxy Health WC |
$62.33
|
| Rate for Payer: Global Benefits Group Commercial |
$44.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$46.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Multiplan Commercial |
$58.66
|
| Rate for Payer: Networks By Design Commercial |
$47.66
|
| Rate for Payer: Prime Health Services Commercial |
$62.33
|
|
|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
IP
|
$73.33
|
|
|
Service Code
|
NDC 6630231002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$62.33 |
| Rate for Payer: Adventist Health Commercial |
$14.67
|
| Rate for Payer: Blue Shield of California Commercial |
$37.18
|
| Rate for Payer: Blue Shield of California Commercial |
$56.39
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna of CA HMO |
$51.33
|
| Rate for Payer: Cigna of CA PPO |
$51.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$51.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.33
|
| Rate for Payer: EPIC Health Plan Senior |
$29.33
|
| Rate for Payer: Galaxy Health WC |
$62.33
|
| Rate for Payer: Global Benefits Group Commercial |
$44.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$46.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Multiplan Commercial |
$58.66
|
| Rate for Payer: Networks By Design Commercial |
$47.66
|
| Rate for Payer: Prime Health Services Commercial |
$62.33
|
|
|
TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE [205151]
|
Facility
|
OP
|
$73.33
|
|
|
Service Code
|
NDC 6630231001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$62.33 |
| Rate for Payer: Adventist Health Commercial |
$14.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$48.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$47.06
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna of CA HMO |
$51.33
|
| Rate for Payer: Cigna of CA PPO |
$51.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$62.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$51.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.33
|
| Rate for Payer: EPIC Health Plan Senior |
$29.33
|
| Rate for Payer: Galaxy Health WC |
$62.33
|
| Rate for Payer: Global Benefits Group Commercial |
$44.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$46.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$51.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.33
|
| Rate for Payer: Multiplan Commercial |
$58.66
|
| Rate for Payer: Networks By Design Commercial |
$47.66
|
| Rate for Payer: Prime Health Services Commercial |
$62.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$44.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$44.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.66
|
| Rate for Payer: United Healthcare All Other HMO |
$36.66
|
| Rate for Payer: United Healthcare HMO Rider |
$36.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.33
|
| Rate for Payer: Vantage Medical Group Senior |
$62.33
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
OP
|
$183.33
|
|
|
Service Code
|
NDC 6630232501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.67 |
| Max. Negotiated Rate |
$155.83 |
| Rate for Payer: Adventist Health Commercial |
$36.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$155.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$128.33
|
| Rate for Payer: Cigna of CA PPO |
$128.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$155.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$155.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$155.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Senior |
$73.33
|
| Rate for Payer: Galaxy Health WC |
$155.83
|
| Rate for Payer: Global Benefits Group Commercial |
$110.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$66.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$128.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.33
|
| Rate for Payer: Multiplan Commercial |
$146.66
|
| Rate for Payer: Networks By Design Commercial |
$119.16
|
| Rate for Payer: Prime Health Services Commercial |
$155.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.67
|
| Rate for Payer: United Healthcare All Other HMO |
$91.67
|
| Rate for Payer: United Healthcare HMO Rider |
$91.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$91.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$155.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$155.83
|
| Rate for Payer: Vantage Medical Group Senior |
$155.83
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
IP
|
$183.33
|
|
|
Service Code
|
NDC 6630232501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.67 |
| Max. Negotiated Rate |
$155.83 |
| Rate for Payer: Adventist Health Commercial |
$36.67
|
| Rate for Payer: Blue Shield of California Commercial |
$140.98
|
| Rate for Payer: Blue Shield of California Commercial |
$92.95
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$128.33
|
| Rate for Payer: Cigna of CA PPO |
$128.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Senior |
$73.33
|
| Rate for Payer: Galaxy Health WC |
$155.83
|
| Rate for Payer: Global Benefits Group Commercial |
$110.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.00
|
| Rate for Payer: Multiplan Commercial |
$146.66
|
| Rate for Payer: Networks By Design Commercial |
$119.16
|
| Rate for Payer: Prime Health Services Commercial |
$155.83
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
OP
|
$183.33
|
|
|
Service Code
|
NDC 6630232502
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.67 |
| Max. Negotiated Rate |
$155.83 |
| Rate for Payer: Adventist Health Commercial |
$36.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$120.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$155.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.64
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$128.33
|
| Rate for Payer: Cigna of CA PPO |
$128.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$155.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$155.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$155.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Senior |
$73.33
|
| Rate for Payer: Galaxy Health WC |
$155.83
|
| Rate for Payer: Global Benefits Group Commercial |
$110.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$66.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$128.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$128.33
|
| Rate for Payer: Multiplan Commercial |
$146.66
|
| Rate for Payer: Networks By Design Commercial |
$119.16
|
| Rate for Payer: Prime Health Services Commercial |
$155.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.67
|
| Rate for Payer: United Healthcare All Other HMO |
$91.67
|
| Rate for Payer: United Healthcare HMO Rider |
$91.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$91.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$155.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$155.83
|
| Rate for Payer: Vantage Medical Group Senior |
$155.83
|
|
|
TREPROSTINIL DIOLAMINE ER 2.5 MG TABLET,EXTENDED RELEASE [205152]
|
Facility
|
IP
|
$183.33
|
|
|
Service Code
|
NDC 6630232502
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.67 |
| Max. Negotiated Rate |
$155.83 |
| Rate for Payer: Adventist Health Commercial |
$36.67
|
| Rate for Payer: Blue Shield of California Commercial |
$140.98
|
| Rate for Payer: Blue Shield of California Commercial |
$92.95
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO |
$128.33
|
| Rate for Payer: Cigna of CA PPO |
$128.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Senior |
$73.33
|
| Rate for Payer: Galaxy Health WC |
$155.83
|
| Rate for Payer: Global Benefits Group Commercial |
$110.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.00
|
| Rate for Payer: Multiplan Commercial |
$146.66
|
| Rate for Payer: Networks By Design Commercial |
$119.16
|
| Rate for Payer: Prime Health Services Commercial |
$155.83
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$366.66
|
|
|
Service Code
|
NDC 6630235002
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$73.33 |
| Max. Negotiated Rate |
$311.66 |
| Rate for Payer: Adventist Health Commercial |
$73.33
|
| Rate for Payer: Blue Shield of California Commercial |
$185.90
|
| Rate for Payer: Blue Shield of California Commercial |
$281.96
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna of CA HMO |
$256.66
|
| Rate for Payer: Cigna of CA PPO |
$256.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$256.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.66
|
| Rate for Payer: EPIC Health Plan Senior |
$146.66
|
| Rate for Payer: Galaxy Health WC |
$311.66
|
| Rate for Payer: Global Benefits Group Commercial |
$220.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$232.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$216.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$293.33
|
| Rate for Payer: Networks By Design Commercial |
$238.33
|
| Rate for Payer: Prime Health Services Commercial |
$311.66
|
|
|
TREPROSTINIL DIOLAMINE ER 5 MG TABLET, EXTENDED RELEASE [218793]
|
Facility
|
IP
|
$366.66
|
|
|
Service Code
|
NDC 6630235001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$73.33 |
| Max. Negotiated Rate |
$311.66 |
| Rate for Payer: Adventist Health Commercial |
$73.33
|
| Rate for Payer: Blue Shield of California Commercial |
$185.90
|
| Rate for Payer: Blue Shield of California Commercial |
$281.96
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna of CA HMO |
$256.66
|
| Rate for Payer: Cigna of CA PPO |
$256.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$256.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.66
|
| Rate for Payer: EPIC Health Plan Senior |
$146.66
|
| Rate for Payer: Galaxy Health WC |
$311.66
|
| Rate for Payer: Global Benefits Group Commercial |
$220.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$232.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$216.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.00
|
| Rate for Payer: Multiplan Commercial |
$293.33
|
| Rate for Payer: Networks By Design Commercial |
$238.33
|
| Rate for Payer: Prime Health Services Commercial |
$311.66
|
|
