|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 5107957520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Senior |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 5107957520
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Senior |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 5107957501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.98
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Senior |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO |
$1.54
|
| Rate for Payer: United Healthcare HMO Rider |
$1.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET [8162]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 5107957501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO |
$2.16
|
| Rate for Payer: Cigna of CA PPO |
$2.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Senior |
$1.23
|
| Rate for Payer: Galaxy Health WC |
$2.62
|
| Rate for Payer: Global Benefits Group Commercial |
$1.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$2.00
|
| Rate for Payer: Prime Health Services Commercial |
$2.62
|
|
|
TRIFLUOPERAZINE 1 MG TABLET [8161]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 5107957220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
TRIFLUOPERAZINE 1 MG TABLET [8161]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 5107957220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
TRIFLUOPERAZINE 2 MG TABLET [8163]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 5107957301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.28
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
TRIFLUOPERAZINE 2 MG TABLET [8163]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 5107957301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$1.40
|
| Rate for Payer: Cigna of CA PPO |
$1.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.80
|
| Rate for Payer: EPIC Health Plan Senior |
$0.80
|
| Rate for Payer: Galaxy Health WC |
$1.70
|
| Rate for Payer: Global Benefits Group Commercial |
$1.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.30
|
| Rate for Payer: Prime Health Services Commercial |
$1.70
|
|
|
TRIFLUOPERAZINE 5 MG TABLET [8164]
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 5107957420
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.64
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.78
|
| Rate for Payer: Cigna of CA PPO |
$1.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.17
|
| Rate for Payer: Global Benefits Group Commercial |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.78
|
| Rate for Payer: Multiplan Commercial |
$2.04
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1.27
|
| Rate for Payer: United Healthcare HMO Rider |
$1.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Vantage Medical Group Senior |
$2.17
|
|
|
TRIFLUOPERAZINE 5 MG TABLET [8164]
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 5107957420
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.78
|
| Rate for Payer: Cigna of CA PPO |
$1.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.17
|
| Rate for Payer: Global Benefits Group Commercial |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.04
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.17
|
|
|
TRIFLURIDINE 1 % EYE DROPS [11595]
|
Facility
|
IP
|
$31.36
|
|
|
Service Code
|
NDC 6131404475
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$26.66 |
| Rate for Payer: Adventist Health Commercial |
$6.27
|
| Rate for Payer: Blue Shield of California Commercial |
$15.90
|
| Rate for Payer: Blue Shield of California Commercial |
$24.12
|
| Rate for Payer: Cash Price |
$14.11
|
| Rate for Payer: Cigna of CA HMO |
$21.95
|
| Rate for Payer: Cigna of CA PPO |
$21.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.54
|
| Rate for Payer: EPIC Health Plan Senior |
$12.54
|
| Rate for Payer: Galaxy Health WC |
$26.66
|
| Rate for Payer: Global Benefits Group Commercial |
$18.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Multiplan Commercial |
$25.09
|
| Rate for Payer: Networks By Design Commercial |
$20.38
|
| Rate for Payer: Prime Health Services Commercial |
$26.66
|
|
|
TRIFLURIDINE 1 % EYE DROPS [11595]
|
Facility
|
OP
|
$31.36
|
|
|
Service Code
|
NDC 6131404475
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$26.66 |
| Rate for Payer: Adventist Health Commercial |
$6.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.12
|
| Rate for Payer: Cash Price |
$14.11
|
| Rate for Payer: Cigna of CA HMO |
$21.95
|
| Rate for Payer: Cigna of CA PPO |
$21.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$26.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.54
|
| Rate for Payer: EPIC Health Plan Senior |
$12.54
|
| Rate for Payer: Galaxy Health WC |
$26.66
|
| Rate for Payer: Global Benefits Group Commercial |
$18.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.95
|
| Rate for Payer: Multiplan Commercial |
$25.09
|
| Rate for Payer: Networks By Design Commercial |
$20.38
|
| Rate for Payer: Prime Health Services Commercial |
$26.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.68
|
| Rate for Payer: United Healthcare All Other HMO |
$15.68
|
| Rate for Payer: United Healthcare HMO Rider |
$15.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.66
|
| Rate for Payer: Vantage Medical Group Senior |
$26.66
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET [8166]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 7095421210
|
| 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
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET [8166]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 7095421210
|
| 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
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET [8166]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0591533501
|
| 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
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET [8166]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0591533501
|
| 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
|
|
|
TRIHEXYPHENIDYL 5 MG TABLET [8167]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 7095421110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
TRIHEXYPHENIDYL 5 MG TABLET [8167]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 0591533701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
TRIHEXYPHENIDYL 5 MG TABLET [8167]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 0591533701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TRIHEXYPHENIDYL 5 MG TABLET [8167]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 7095421110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION [110953]
|
Facility
|
IP
|
$39.65
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$33.70 |
| Rate for Payer: Adventist Health Commercial |
$7.93
|
| Rate for Payer: Blue Shield of California Commercial |
$20.10
|
| Rate for Payer: Blue Shield of California Commercial |
$30.49
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna of CA HMO |
$27.75
|
| Rate for Payer: Cigna of CA PPO |
$27.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$27.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.86
|
| Rate for Payer: EPIC Health Plan Senior |
$15.86
|
| Rate for Payer: Galaxy Health WC |
$33.70
|
| Rate for Payer: Global Benefits Group Commercial |
$23.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$25.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.52
|
| Rate for Payer: Multiplan Commercial |
$31.72
|
| Rate for Payer: Networks By Design Commercial |
$19.82
|
| Rate for Payer: Prime Health Services Commercial |
$33.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.88
|
| Rate for Payer: United Healthcare All Other HMO |
$14.48
|
| Rate for Payer: United Healthcare HMO Rider |
$14.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.99
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION [110953]
|
Facility
|
OP
|
$39.65
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$314.72 |
| Rate for Payer: Adventist Health Commercial |
$7.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$314.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.76
|
| Rate for Payer: Blue Shield of California Commercial |
$63.26
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna of CA HMO |
$27.75
|
| Rate for Payer: Cigna of CA PPO |
$27.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$33.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$27.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.86
|
| Rate for Payer: EPIC Health Plan Senior |
$15.86
|
| Rate for Payer: Galaxy Health WC |
$33.70
|
| Rate for Payer: Global Benefits Group Commercial |
$23.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$62.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$25.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$31.72
|
| Rate for Payer: Networks By Design Commercial |
$19.82
|
| Rate for Payer: Prime Health Services Commercial |
$33.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.88
|
| Rate for Payer: United Healthcare All Other HMO |
$14.48
|
| Rate for Payer: United Healthcare HMO Rider |
$14.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.70
|
| Rate for Payer: Vantage Medical Group Senior |
$33.70
|
|
|
TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Senior |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
TROMETHAMINE 36 MG/ML (0.3 M) INTRAVENOUS SOLUTION [11608]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Senior |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
|
|
TROPICAMIDE 0.5 % EYE DROPS [8249]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
NDC 6131435401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.20
|
| Rate for Payer: Cigna of CA PPO |
$1.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Senior |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
| Rate for Payer: Networks By Design Commercial |
$1.11
|
| Rate for Payer: Prime Health Services Commercial |
$1.45
|
|
