|
TARLATAMAB-DLLE 1 MG INTRAVENOUS SOLUTION [241612]
|
Facility
|
IP
|
$1,854.00
|
|
|
Service Code
|
HCPCS J9026
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$370.80 |
| Max. Negotiated Rate |
$1,668.60 |
| Rate for Payer: Adventist Health Commercial |
$370.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1,486.91
|
| Rate for Payer: Blue Shield of California EPN |
$934.42
|
| Rate for Payer: Cash Price |
$834.30
|
| Rate for Payer: Central Health Plan Commercial |
$1,483.20
|
| Rate for Payer: Cigna of CA HMO |
$1,297.80
|
| Rate for Payer: Cigna of CA PPO |
$1,297.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,297.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$741.60
|
| Rate for Payer: EPIC Health Plan Senior |
$741.60
|
| Rate for Payer: Galaxy Health WC |
$1,575.90
|
| Rate for Payer: Global Benefits Group Commercial |
$1,112.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,668.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,177.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,093.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$370.80
|
| Rate for Payer: Multiplan Commercial |
$1,390.50
|
| Rate for Payer: Networks By Design Commercial |
$927.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,575.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$695.81
|
| Rate for Payer: United Healthcare All Other HMO |
$677.27
|
| Rate for Payer: United Healthcare HMO Rider |
$662.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$607.18
|
|
|
TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11921
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$639.21 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$950.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$1,239.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1,017.03
|
| Rate for Payer: Blue Shield of California EPN |
$639.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,568.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1,045.63
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,558.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,330.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$950.57
|
| Rate for Payer: Preferred Health Network WC |
$1,264.53
|
| Rate for Payer: Prime Health Services Medicare |
$1,007.60
|
| Rate for Payer: Prime Health Services WC |
$1,226.59
|
| Rate for Payer: Riverside University Health System MISP |
$1,045.63
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$950.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
NDC 7260710000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Adventist Health Commercial |
$21.40
|
| Rate for Payer: Blue Shield of California Commercial |
$85.81
|
| Rate for Payer: Blue Shield of California EPN |
$53.93
|
| Rate for Payer: Cash Price |
$48.15
|
| Rate for Payer: Central Health Plan Commercial |
$85.60
|
| Rate for Payer: Cigna of CA HMO |
$74.90
|
| Rate for Payer: Cigna of CA PPO |
$74.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.80
|
| Rate for Payer: EPIC Health Plan Senior |
$42.80
|
| Rate for Payer: Galaxy Health WC |
$90.95
|
| Rate for Payer: Global Benefits Group Commercial |
$64.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$96.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$63.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.40
|
| Rate for Payer: Multiplan Commercial |
$80.25
|
| Rate for Payer: Networks By Design Commercial |
$69.55
|
| Rate for Payer: Prime Health Services Commercial |
$90.95
|
|
|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
NDC 7260710000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Adventist Health Commercial |
$21.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$64.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$80.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.24
|
| Rate for Payer: Blue Shield of California Commercial |
$67.84
|
| Rate for Payer: Blue Shield of California EPN |
$42.69
|
| Rate for Payer: Cash Price |
$48.15
|
| Rate for Payer: Central Health Plan Commercial |
$85.60
|
| Rate for Payer: Cigna of CA HMO |
$74.90
|
| Rate for Payer: Cigna of CA PPO |
$74.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.80
|
| Rate for Payer: EPIC Health Plan Senior |
$42.80
|
| Rate for Payer: Galaxy Health WC |
$90.95
|
| Rate for Payer: Global Benefits Group Commercial |
$64.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$96.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$63.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$74.90
|
| Rate for Payer: Multiplan Commercial |
$80.25
|
| Rate for Payer: Networks By Design Commercial |
$69.55
|
| Rate for Payer: Prime Health Services Commercial |
$90.95
|
| Rate for Payer: Riverside University Health System MISP |
$42.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$53.50
|
| Rate for Payer: United Healthcare All Other HMO |
$53.50
|
| Rate for Payer: United Healthcare HMO Rider |
$53.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.95
|
| Rate for Payer: Vantage Medical Group Senior |
$90.95
|
|
|
TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION [233477]
|
Facility
|
OP
|
$51,624.00
|
|
|
Service Code
|
HCPCS J9274
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.01 |
| Max. Negotiated Rate |
$46,461.60 |
| Rate for Payer: Adventist Health Commercial |
$10,324.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$228.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,330.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$285.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$250.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$371.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$463.26
|
| Rate for Payer: Blue Shield of California Commercial |
$267.43
|
| Rate for Payer: Blue Shield of California EPN |
$243.12
|
| Rate for Payer: Cash Price |
$23,230.80
|
| Rate for Payer: Cash Price |
$23,230.80
|
| Rate for Payer: Central Health Plan Commercial |
$41,299.20
|
| Rate for Payer: Cigna of CA HMO |
$36,136.80
|
| Rate for Payer: Cigna of CA PPO |
$36,136.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$285.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$250.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$250.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36,136.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$376.22
|
| Rate for Payer: EPIC Health Plan Senior |
$250.81
|
| Rate for Payer: Galaxy Health WC |
$43,880.40
|
| Rate for Payer: Global Benefits Group Commercial |
$30,974.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$46,461.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$373.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$228.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$228.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$32,781.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$422.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$319.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,324.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$305.53
|
| Rate for Payer: Multiplan Commercial |
$38,718.00
|
| Rate for Payer: Networks By Design Commercial |
$25,812.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$228.01
|
| Rate for Payer: Prime Health Services Commercial |
$43,880.40
|
| Rate for Payer: Prime Health Services Medicare |
$241.69
|
| Rate for Payer: Riverside University Health System MISP |
$250.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30,974.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30,974.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$19,374.49
|
| Rate for Payer: United Healthcare All Other HMO |
$18,858.25
|
| Rate for Payer: United Healthcare HMO Rider |
$18,450.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,906.86
|
| Rate for Payer: Upland Medical Group Pediatric |
$228.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$285.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$250.81
|
| Rate for Payer: Vantage Medical Group Senior |
$250.81
|
|
|
TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION [233477]
|
Facility
|
IP
|
$51,624.00
|
|
|
Service Code
|
HCPCS J9274
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,324.80 |
| Max. Negotiated Rate |
$46,461.60 |
| Rate for Payer: Adventist Health Commercial |
$10,324.80
|
| Rate for Payer: Blue Shield of California Commercial |
$41,402.45
|
| Rate for Payer: Blue Shield of California EPN |
$26,018.50
|
| Rate for Payer: Cash Price |
$23,230.80
|
| Rate for Payer: Central Health Plan Commercial |
$41,299.20
|
| Rate for Payer: Cigna of CA HMO |
$36,136.80
|
| Rate for Payer: Cigna of CA PPO |
$36,136.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$36,136.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,649.60
|
| Rate for Payer: EPIC Health Plan Senior |
$20,649.60
|
| Rate for Payer: Galaxy Health WC |
$43,880.40
|
| Rate for Payer: Global Benefits Group Commercial |
$30,974.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$46,461.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$32,781.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$30,458.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,324.80
|
| Rate for Payer: Multiplan Commercial |
$38,718.00
|
| Rate for Payer: Networks By Design Commercial |
$25,812.00
|
| Rate for Payer: Prime Health Services Commercial |
$43,880.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$19,374.49
|
| Rate for Payer: United Healthcare All Other HMO |
$18,858.25
|
| Rate for Payer: United Healthcare HMO Rider |
$18,450.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,906.86
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
|
IP
|
$849.73
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.95 |
| Max. Negotiated Rate |
$764.76 |
| Rate for Payer: Adventist Health Commercial |
$169.95
|
| Rate for Payer: Blue Shield of California Commercial |
$681.48
|
| Rate for Payer: Blue Shield of California EPN |
$428.26
|
| Rate for Payer: Cash Price |
$382.38
|
| Rate for Payer: Central Health Plan Commercial |
$679.78
|
| Rate for Payer: Cigna of CA HMO |
$594.81
|
| Rate for Payer: Cigna of CA PPO |
$594.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$594.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$339.89
|
| Rate for Payer: EPIC Health Plan Senior |
$339.89
|
| Rate for Payer: Galaxy Health WC |
$722.27
|
| Rate for Payer: Global Benefits Group Commercial |
$509.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$764.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$539.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$501.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.95
|
| Rate for Payer: Multiplan Commercial |
$637.30
|
| Rate for Payer: Networks By Design Commercial |
$424.87
|
| Rate for Payer: Prime Health Services Commercial |
$722.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$318.90
|
| Rate for Payer: United Healthcare All Other HMO |
$310.41
|
| Rate for Payer: United Healthcare HMO Rider |
$303.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$278.29
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
|
OP
|
$849.73
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$764.76 |
| Rate for Payer: Adventist Health Commercial |
$169.95
|
| Rate for Payer: Adventist Health Medi-Cal |
$35.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$200.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$38.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$411.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$494.29
|
| Rate for Payer: Blue Shield of California Commercial |
$41.91
|
| Rate for Payer: Blue Shield of California EPN |
$38.10
|
| Rate for Payer: Cash Price |
$382.38
|
| Rate for Payer: Cash Price |
$382.38
|
| Rate for Payer: Central Health Plan Commercial |
$679.78
|
| Rate for Payer: Cigna of CA HMO |
$594.81
|
| Rate for Payer: Cigna of CA PPO |
$594.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$38.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$594.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.28
|
| Rate for Payer: EPIC Health Plan Senior |
$38.85
|
| Rate for Payer: Galaxy Health WC |
$722.27
|
| Rate for Payer: Global Benefits Group Commercial |
$509.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$764.76
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$57.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$35.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$539.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$169.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.33
|
| Rate for Payer: Multiplan Commercial |
$637.30
|
| Rate for Payer: Networks By Design Commercial |
$424.87
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$35.32
|
| Rate for Payer: Prime Health Services Commercial |
$722.27
|
| Rate for Payer: Prime Health Services Medicare |
$37.44
|
| Rate for Payer: Riverside University Health System MISP |
$38.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$509.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$509.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$318.90
|
| Rate for Payer: United Healthcare All Other HMO |
$310.41
|
| Rate for Payer: United Healthcare HMO Rider |
$303.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$278.29
|
| Rate for Payer: Upland Medical Group Pediatric |
$35.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.85
|
| Rate for Payer: Vantage Medical Group Senior |
$38.85
|
|
|
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION [236038]
|
Facility
|
IP
|
$7,647.61
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,529.52 |
| Max. Negotiated Rate |
$6,882.85 |
| Rate for Payer: Adventist Health Commercial |
$1,529.52
|
| Rate for Payer: Blue Shield of California Commercial |
$6,133.38
|
| Rate for Payer: Blue Shield of California EPN |
$3,854.40
|
| Rate for Payer: Cash Price |
$3,441.42
|
| Rate for Payer: Central Health Plan Commercial |
$6,118.09
|
| Rate for Payer: Cigna of CA HMO |
$5,353.33
|
| Rate for Payer: Cigna of CA PPO |
$5,353.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,353.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,059.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3,059.04
|
| Rate for Payer: Galaxy Health WC |
$6,500.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4,588.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$6,882.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,856.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,512.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,529.52
|
| Rate for Payer: Multiplan Commercial |
$5,735.71
|
| Rate for Payer: Networks By Design Commercial |
$3,823.80
|
| Rate for Payer: Prime Health Services Commercial |
$6,500.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,870.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2,793.67
|
| Rate for Payer: United Healthcare HMO Rider |
$2,733.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,504.59
|
|
|
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION [236038]
|
Facility
|
OP
|
$7,647.61
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$6,882.85 |
| Rate for Payer: Adventist Health Commercial |
$1,529.52
|
| Rate for Payer: Adventist Health Medi-Cal |
$35.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$200.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$38.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,702.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,448.61
|
| Rate for Payer: Blue Shield of California Commercial |
$41.91
|
| Rate for Payer: Blue Shield of California EPN |
$38.10
|
| Rate for Payer: Cash Price |
$3,441.42
|
| Rate for Payer: Cash Price |
$3,441.42
|
| Rate for Payer: Central Health Plan Commercial |
$6,118.09
|
| Rate for Payer: Cigna of CA HMO |
$5,353.33
|
| Rate for Payer: Cigna of CA PPO |
$5,353.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$44.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$38.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5,353.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.28
|
| Rate for Payer: EPIC Health Plan Senior |
$38.85
|
| Rate for Payer: Galaxy Health WC |
$6,500.47
|
| Rate for Payer: Global Benefits Group Commercial |
$4,588.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$6,882.85
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$57.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$35.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4,856.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,529.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47.33
|
| Rate for Payer: Multiplan Commercial |
$5,735.71
|
| Rate for Payer: Networks By Design Commercial |
$3,823.80
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$35.32
|
| Rate for Payer: Prime Health Services Commercial |
$6,500.47
|
| Rate for Payer: Prime Health Services Medicare |
$37.44
|
| Rate for Payer: Riverside University Health System MISP |
$38.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,588.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,588.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,870.15
|
| Rate for Payer: United Healthcare All Other HMO |
$2,793.67
|
| Rate for Payer: United Healthcare HMO Rider |
$2,733.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,504.59
|
| Rate for Payer: Upland Medical Group Pediatric |
$35.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$44.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.85
|
| Rate for Payer: Vantage Medical Group Senior |
$38.85
|
|
|
TELISOTUZUMAB VEDOTIN-TLLV 100 MG INTRAVENOUS SOLUTION [246066]
|
Facility
|
IP
|
$16,776.00
|
|
|
Service Code
|
HCPCS J9326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,355.20 |
| Max. Negotiated Rate |
$15,098.40 |
| Rate for Payer: Adventist Health Commercial |
$3,355.20
|
| Rate for Payer: Blue Shield of California Commercial |
$13,454.35
|
| Rate for Payer: Blue Shield of California EPN |
$8,455.10
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Central Health Plan Commercial |
$13,420.80
|
| Rate for Payer: Cigna of CA HMO |
$11,743.20
|
| Rate for Payer: Cigna of CA PPO |
$11,743.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,743.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,710.40
|
| Rate for Payer: EPIC Health Plan Senior |
$6,710.40
|
| Rate for Payer: Galaxy Health WC |
$14,259.60
|
| Rate for Payer: Global Benefits Group Commercial |
$10,065.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$15,098.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,652.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,897.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,355.20
|
| Rate for Payer: Multiplan Commercial |
$12,582.00
|
| Rate for Payer: Networks By Design Commercial |
$8,388.00
|
| Rate for Payer: Prime Health Services Commercial |
$14,259.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,296.03
|
| Rate for Payer: United Healthcare All Other HMO |
$6,128.27
|
| Rate for Payer: United Healthcare HMO Rider |
$5,995.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,494.14
|
|
|
TELISOTUZUMAB VEDOTIN-TLLV 100 MG INTRAVENOUS SOLUTION [246066]
|
Facility
|
OP
|
$16,776.00
|
|
|
Service Code
|
HCPCS J9326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.06 |
| Max. Negotiated Rate |
$15,098.40 |
| Rate for Payer: Adventist Health Commercial |
$3,355.20
|
| Rate for Payer: Adventist Health Medi-Cal |
$146.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,188.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$219.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$160.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$146.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$276.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$345.28
|
| Rate for Payer: Blue Shield of California Commercial |
$10,635.98
|
| Rate for Payer: Blue Shield of California EPN |
$6,693.62
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Cash Price |
$7,549.20
|
| Rate for Payer: Central Health Plan Commercial |
$13,420.80
|
| Rate for Payer: Cigna of CA HMO |
$11,743.20
|
| Rate for Payer: Cigna of CA PPO |
$11,743.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$219.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$146.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,743.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.00
|
| Rate for Payer: EPIC Health Plan Senior |
$160.67
|
| Rate for Payer: Galaxy Health WC |
$14,259.60
|
| Rate for Payer: Global Benefits Group Commercial |
$10,065.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$15,098.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$239.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$146.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$146.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,652.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$277.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$204.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,355.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$195.72
|
| Rate for Payer: Multiplan Commercial |
$12,582.00
|
| Rate for Payer: Networks By Design Commercial |
$8,388.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$146.06
|
| Rate for Payer: Prime Health Services Commercial |
$14,259.60
|
| Rate for Payer: Prime Health Services Medicare |
$154.82
|
| Rate for Payer: Riverside University Health System MISP |
$160.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10,065.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10,065.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,296.03
|
| Rate for Payer: United Healthcare All Other HMO |
$6,128.27
|
| Rate for Payer: United Healthcare HMO Rider |
$5,995.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,494.14
|
| Rate for Payer: Upland Medical Group Pediatric |
$146.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$219.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.67
|
| Rate for Payer: Vantage Medical Group Senior |
$146.06
|
|
|
TELISOTUZUMAB VEDOTIN-TLLV 20 MG INTRAVENOUS SOLUTION [246067]
|
Facility
|
IP
|
$3,355.20
|
|
|
Service Code
|
HCPCS J9326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$671.04 |
| Max. Negotiated Rate |
$3,019.68 |
| Rate for Payer: Adventist Health Commercial |
$671.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2,690.87
|
| Rate for Payer: Blue Shield of California EPN |
$1,691.02
|
| Rate for Payer: Cash Price |
$1,509.84
|
| Rate for Payer: Central Health Plan Commercial |
$2,684.16
|
| Rate for Payer: Cigna of CA HMO |
$2,348.64
|
| Rate for Payer: Cigna of CA PPO |
$2,348.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,348.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,342.08
|
| Rate for Payer: EPIC Health Plan Senior |
$1,342.08
|
| Rate for Payer: Galaxy Health WC |
$2,851.92
|
| Rate for Payer: Global Benefits Group Commercial |
$2,013.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,019.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,130.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,979.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$671.04
|
| Rate for Payer: Multiplan Commercial |
$2,516.40
|
| Rate for Payer: Networks By Design Commercial |
$1,677.60
|
| Rate for Payer: Prime Health Services Commercial |
$2,851.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,259.21
|
| Rate for Payer: United Healthcare All Other HMO |
$1,225.65
|
| Rate for Payer: United Healthcare HMO Rider |
$1,199.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,098.83
|
|
|
TELISOTUZUMAB VEDOTIN-TLLV 20 MG INTRAVENOUS SOLUTION [246067]
|
Facility
|
OP
|
$3,355.20
|
|
|
Service Code
|
HCPCS J9326
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.06 |
| Max. Negotiated Rate |
$3,019.68 |
| Rate for Payer: Adventist Health Commercial |
$671.04
|
| Rate for Payer: Adventist Health Medi-Cal |
$146.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,037.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$219.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$160.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$146.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$276.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$345.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,127.20
|
| Rate for Payer: Blue Shield of California EPN |
$1,338.72
|
| Rate for Payer: Cash Price |
$1,509.84
|
| Rate for Payer: Cash Price |
$1,509.84
|
| Rate for Payer: Central Health Plan Commercial |
$2,684.16
|
| Rate for Payer: Cigna of CA HMO |
$2,348.64
|
| Rate for Payer: Cigna of CA PPO |
$2,348.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$219.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$160.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$146.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,348.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.00
|
| Rate for Payer: EPIC Health Plan Senior |
$160.67
|
| Rate for Payer: Galaxy Health WC |
$2,851.92
|
| Rate for Payer: Global Benefits Group Commercial |
$2,013.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,019.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$239.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$146.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$146.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,130.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$277.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$204.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$671.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$195.72
|
| Rate for Payer: Multiplan Commercial |
$2,516.40
|
| Rate for Payer: Networks By Design Commercial |
$1,677.60
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$146.06
|
| Rate for Payer: Prime Health Services Commercial |
$2,851.92
|
| Rate for Payer: Prime Health Services Medicare |
$154.82
|
| Rate for Payer: Riverside University Health System MISP |
$160.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,013.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,013.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,259.21
|
| Rate for Payer: United Healthcare All Other HMO |
$1,225.65
|
| Rate for Payer: United Healthcare HMO Rider |
$1,199.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,098.83
|
| Rate for Payer: Upland Medical Group Pediatric |
$146.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$219.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$160.67
|
| Rate for Payer: Vantage Medical Group Senior |
$146.06
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597004037
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Senior |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
| Rate for Payer: Riverside University Health System MISP |
$2.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.81
|
| Rate for Payer: United Healthcare All Other HMO |
$2.81
|
| Rate for Payer: United Healthcare HMO Rider |
$2.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597004037
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$2.83
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Senior |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597004137
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$2.83
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Senior |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597004137
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Central Health Plan Commercial |
$4.49
|
| Rate for Payer: Cigna of CA HMO |
$3.93
|
| Rate for Payer: Cigna of CA PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.24
|
| Rate for Payer: EPIC Health Plan Senior |
$2.24
|
| Rate for Payer: Galaxy Health WC |
$4.77
|
| Rate for Payer: Global Benefits Group Commercial |
$3.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.93
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Networks By Design Commercial |
$3.65
|
| Rate for Payer: Prime Health Services Commercial |
$4.77
|
| Rate for Payer: Riverside University Health System MISP |
$2.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.81
|
| Rate for Payer: United Healthcare All Other HMO |
$2.81
|
| Rate for Payer: United Healthcare HMO Rider |
$2.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6787714605
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 6787714601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0228207610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0228207610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 6787714601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6787714605
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 30 MG CAPSULE [7754]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0378505001
|
| 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 |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
