|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 6255972201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.24
|
| Rate for Payer: Riverside University Health System MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Other HMO |
$0.73
|
| Rate for Payer: United Healthcare HMO Rider |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1.24
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 2497913301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 6255972201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.24
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
OP
|
$1,256.40
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$251.28 |
| Max. Negotiated Rate |
$1,130.76 |
| Rate for Payer: Adventist Health Commercial |
$251.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$763.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$691.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$942.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$608.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$730.85
|
| Rate for Payer: Blue Shield of California Commercial |
$796.56
|
| Rate for Payer: Blue Shield of California EPN |
$501.30
|
| Rate for Payer: Cash Price |
$565.38
|
| Rate for Payer: Central Health Plan Commercial |
$1,005.12
|
| Rate for Payer: Cigna of CA HMO |
$879.48
|
| Rate for Payer: Cigna of CA PPO |
$879.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,067.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,067.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$879.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$502.56
|
| Rate for Payer: EPIC Health Plan Senior |
$502.56
|
| Rate for Payer: Galaxy Health WC |
$1,067.94
|
| Rate for Payer: Global Benefits Group Commercial |
$753.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,130.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$797.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$456.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$741.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$251.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$879.48
|
| Rate for Payer: Multiplan Commercial |
$942.30
|
| Rate for Payer: Networks By Design Commercial |
$628.20
|
| Rate for Payer: Prime Health Services Commercial |
$1,067.94
|
| Rate for Payer: Riverside University Health System MISP |
$502.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$753.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$753.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$471.53
|
| Rate for Payer: United Healthcare All Other HMO |
$458.96
|
| Rate for Payer: United Healthcare HMO Rider |
$449.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$411.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,067.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1,067.94
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
IP
|
$1,256.40
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$251.28 |
| Max. Negotiated Rate |
$1,130.76 |
| Rate for Payer: Adventist Health Commercial |
$251.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1,007.63
|
| Rate for Payer: Blue Shield of California EPN |
$633.23
|
| Rate for Payer: Cash Price |
$565.38
|
| Rate for Payer: Central Health Plan Commercial |
$1,005.12
|
| Rate for Payer: Cigna of CA HMO |
$879.48
|
| Rate for Payer: Cigna of CA PPO |
$879.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$879.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$502.56
|
| Rate for Payer: EPIC Health Plan Senior |
$502.56
|
| Rate for Payer: Galaxy Health WC |
$1,067.94
|
| Rate for Payer: Global Benefits Group Commercial |
$753.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,130.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$797.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$741.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$251.28
|
| Rate for Payer: Multiplan Commercial |
$942.30
|
| Rate for Payer: Networks By Design Commercial |
$628.20
|
| Rate for Payer: Prime Health Services Commercial |
$1,067.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$471.53
|
| Rate for Payer: United Healthcare All Other HMO |
$458.96
|
| Rate for Payer: United Healthcare HMO Rider |
$449.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$411.47
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$54,843.53
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$54,843.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54,843.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$35,426.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49,598.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$48,908.41
|
| Rate for Payer: EPIC Health Plan Senior |
$32,605.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29,641.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$41,498.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39,719.56
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29,641.46
|
| Rate for Payer: Prime Health Services Medicare |
$31,419.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$28,943.00
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$28,943.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28,943.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$18,696.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26,175.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$26,513.39
|
| Rate for Payer: EPIC Health Plan Senior |
$17,675.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,068.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22,496.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21,532.08
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$16,068.72
|
| Rate for Payer: Prime Health Services Medicare |
$17,032.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Blue Shield of California Commercial |
$8.41
|
| Rate for Payer: Blue Shield of California EPN |
$5.29
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Central Health Plan Commercial |
$8.39
|
| Rate for Payer: Cigna of CA HMO |
$7.34
|
| Rate for Payer: Cigna of CA PPO |
$7.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: EPIC Health Plan Senior |
$4.20
|
| Rate for Payer: Galaxy Health WC |
$8.92
|
| Rate for Payer: Global Benefits Group Commercial |
$6.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
| Rate for Payer: Networks By Design Commercial |
$5.25
|
| Rate for Payer: Prime Health Services Commercial |
$8.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.94
|
| Rate for Payer: United Healthcare All Other HMO |
$3.83
|
| Rate for Payer: United Healthcare HMO Rider |
$3.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.44
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$9.44 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Central Health Plan Commercial |
$8.39
|
| Rate for Payer: Cigna of CA HMO |
$7.34
|
| Rate for Payer: Cigna of CA PPO |
$7.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$7.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: EPIC Health Plan Senior |
$4.20
|
| Rate for Payer: Galaxy Health WC |
$8.92
|
| Rate for Payer: Global Benefits Group Commercial |
$6.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$9.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$6.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
| Rate for Payer: Networks By Design Commercial |
$5.25
|
| Rate for Payer: Prime Health Services Commercial |
$8.92
|
| Rate for Payer: Riverside University Health System MISP |
$4.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.94
|
| Rate for Payer: United Healthcare All Other HMO |
$3.83
|
| Rate for Payer: United Healthcare HMO Rider |
$3.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.92
|
| Rate for Payer: Vantage Medical Group Senior |
$8.92
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Blue Shield of California Commercial |
$17.84
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Central Health Plan Commercial |
$17.80
|
| Rate for Payer: Cigna of CA HMO |
$15.57
|
| Rate for Payer: Cigna of CA PPO |
$15.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Senior |
$8.90
|
| Rate for Payer: Galaxy Health WC |
$18.91
|
| Rate for Payer: Global Benefits Group Commercial |
$13.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
| Rate for Payer: Networks By Design Commercial |
$11.12
|
| Rate for Payer: Prime Health Services Commercial |
$18.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.35
|
| Rate for Payer: United Healthcare All Other HMO |
$8.13
|
| Rate for Payer: United Healthcare HMO Rider |
$7.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.29
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Central Health Plan Commercial |
$17.80
|
| Rate for Payer: Cigna of CA HMO |
$15.57
|
| Rate for Payer: Cigna of CA PPO |
$15.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Senior |
$8.90
|
| Rate for Payer: Galaxy Health WC |
$18.91
|
| Rate for Payer: Global Benefits Group Commercial |
$13.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$20.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.57
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
| Rate for Payer: Networks By Design Commercial |
$11.12
|
| Rate for Payer: Prime Health Services Commercial |
$18.91
|
| Rate for Payer: Riverside University Health System MISP |
$8.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.35
|
| Rate for Payer: United Healthcare All Other HMO |
$8.13
|
| Rate for Payer: United Healthcare HMO Rider |
$7.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.91
|
| Rate for Payer: Vantage Medical Group Senior |
$18.91
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
OP
|
$106.59
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.32 |
| Max. Negotiated Rate |
$208.37 |
| Rate for Payer: Adventist Health Commercial |
$21.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$208.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$40.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.29
|
| Rate for Payer: Blue Shield of California Commercial |
$36.95
|
| Rate for Payer: Blue Shield of California EPN |
$33.59
|
| Rate for Payer: Cash Price |
$47.97
|
| Rate for Payer: Cash Price |
$47.97
|
| Rate for Payer: Central Health Plan Commercial |
$85.27
|
| Rate for Payer: Cigna of CA HMO |
$74.61
|
| Rate for Payer: Cigna of CA PPO |
$74.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.64
|
| Rate for Payer: EPIC Health Plan Senior |
$42.64
|
| Rate for Payer: Galaxy Health WC |
$90.60
|
| Rate for Payer: Global Benefits Group Commercial |
$63.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$40.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$82.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$62.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$74.61
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: Networks By Design Commercial |
$53.30
|
| Rate for Payer: Prime Health Services Commercial |
$90.60
|
| Rate for Payer: Riverside University Health System MISP |
$42.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.00
|
| Rate for Payer: United Healthcare All Other HMO |
$38.94
|
| Rate for Payer: United Healthcare HMO Rider |
$38.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.60
|
| Rate for Payer: Vantage Medical Group Senior |
$90.60
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
IP
|
$106.59
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.32 |
| Max. Negotiated Rate |
$95.93 |
| Rate for Payer: Adventist Health Commercial |
$21.32
|
| Rate for Payer: Blue Shield of California Commercial |
$85.49
|
| Rate for Payer: Blue Shield of California EPN |
$53.72
|
| Rate for Payer: Cash Price |
$47.97
|
| Rate for Payer: Central Health Plan Commercial |
$85.27
|
| Rate for Payer: Cigna of CA HMO |
$74.61
|
| Rate for Payer: Cigna of CA PPO |
$74.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.64
|
| Rate for Payer: EPIC Health Plan Senior |
$42.64
|
| Rate for Payer: Galaxy Health WC |
$90.60
|
| Rate for Payer: Global Benefits Group Commercial |
$63.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$62.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.32
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: Networks By Design Commercial |
$53.30
|
| Rate for Payer: Prime Health Services Commercial |
$90.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.00
|
| Rate for Payer: United Healthcare All Other HMO |
$38.94
|
| Rate for Payer: United Healthcare HMO Rider |
$38.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.91
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
OP
|
$786.79
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.36 |
| Max. Negotiated Rate |
$3,568.03 |
| Rate for Payer: Adventist Health Commercial |
$157.36
|
| Rate for Payer: Adventist Health Medi-Cal |
$595.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,568.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$743.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$654.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$654.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$197.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$247.00
|
| Rate for Payer: Blue Shield of California Commercial |
$856.90
|
| Rate for Payer: Blue Shield of California EPN |
$779.00
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Central Health Plan Commercial |
$629.43
|
| Rate for Payer: Cigna of CA HMO |
$550.75
|
| Rate for Payer: Cigna of CA PPO |
$550.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$743.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$654.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$654.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$550.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$981.78
|
| Rate for Payer: EPIC Health Plan Senior |
$654.52
|
| Rate for Payer: Galaxy Health WC |
$668.77
|
| Rate for Payer: Global Benefits Group Commercial |
$472.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$708.11
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$975.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$595.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$595.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$499.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,126.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$833.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$797.33
|
| Rate for Payer: Multiplan Commercial |
$590.09
|
| Rate for Payer: Networks By Design Commercial |
$393.39
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$595.02
|
| Rate for Payer: Prime Health Services Commercial |
$668.77
|
| Rate for Payer: Prime Health Services Medicare |
$630.72
|
| Rate for Payer: Riverside University Health System MISP |
$654.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$472.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$472.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.28
|
| Rate for Payer: United Healthcare All Other HMO |
$287.41
|
| Rate for Payer: United Healthcare HMO Rider |
$281.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$257.67
|
| Rate for Payer: Upland Medical Group Pediatric |
$595.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$743.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$654.52
|
| Rate for Payer: Vantage Medical Group Senior |
$654.52
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$786.79
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.36 |
| Max. Negotiated Rate |
$708.11 |
| Rate for Payer: Adventist Health Commercial |
$157.36
|
| Rate for Payer: Blue Shield of California Commercial |
$631.01
|
| Rate for Payer: Blue Shield of California EPN |
$396.54
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Central Health Plan Commercial |
$629.43
|
| Rate for Payer: Cigna of CA HMO |
$550.75
|
| Rate for Payer: Cigna of CA PPO |
$550.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$550.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$314.72
|
| Rate for Payer: EPIC Health Plan Senior |
$314.72
|
| Rate for Payer: Galaxy Health WC |
$668.77
|
| Rate for Payer: Global Benefits Group Commercial |
$472.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$708.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$499.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$464.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.36
|
| Rate for Payer: Multiplan Commercial |
$590.09
|
| Rate for Payer: Networks By Design Commercial |
$393.39
|
| Rate for Payer: Prime Health Services Commercial |
$668.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$295.28
|
| Rate for Payer: United Healthcare All Other HMO |
$287.41
|
| Rate for Payer: United Healthcare HMO Rider |
$281.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$257.67
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California EPN |
$6.26
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Central Health Plan Commercial |
$12.56
|
| Rate for Payer: Cigna of CA HMO |
$10.99
|
| Rate for Payer: Cigna of CA PPO |
$10.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Senior |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.35
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.99
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
| Rate for Payer: Networks By Design Commercial |
$10.21
|
| Rate for Payer: Prime Health Services Commercial |
$13.35
|
| Rate for Payer: Riverside University Health System MISP |
$6.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.85
|
| Rate for Payer: United Healthcare All Other HMO |
$7.85
|
| Rate for Payer: United Healthcare HMO Rider |
$7.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Vantage Medical Group Senior |
$13.35
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.29
|
| Rate for Payer: Cigna of CA HMO |
$1.13
|
| Rate for Payer: Cigna of CA PPO |
$1.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Central Health Plan Commercial |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$1.88
|
| Rate for Payer: Cigna of CA PPO |
$1.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: EPIC Health Plan Senior |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$2.01
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.28
|
| Rate for Payer: Riverside University Health System MISP |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.34
|
| Rate for Payer: United Healthcare HMO Rider |
$1.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.28
|
| Rate for Payer: Vantage Medical Group Senior |
$2.28
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$2.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.35
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Central Health Plan Commercial |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$1.88
|
| Rate for Payer: Cigna of CA PPO |
$1.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: EPIC Health Plan Senior |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.28
|
| Rate for Payer: Global Benefits Group Commercial |
$1.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$2.01
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.28
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$12.59
|
| Rate for Payer: Blue Shield of California EPN |
$7.91
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Central Health Plan Commercial |
$12.56
|
| Rate for Payer: Cigna of CA HMO |
$10.99
|
| Rate for Payer: Cigna of CA PPO |
$10.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Senior |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.35
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
| Rate for Payer: Networks By Design Commercial |
$10.21
|
| Rate for Payer: Prime Health Services Commercial |
$13.35
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
OP
|
$455.76
|
|
|
Service Code
|
NDC 6738642201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.15 |
| Max. Negotiated Rate |
$410.18 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$276.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$250.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$341.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$220.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$265.12
|
| Rate for Payer: Blue Shield of California Commercial |
$288.95
|
| Rate for Payer: Blue Shield of California EPN |
$181.85
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Central Health Plan Commercial |
$364.61
|
| Rate for Payer: Cigna of CA HMO |
$319.03
|
| Rate for Payer: Cigna of CA PPO |
$319.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$387.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$387.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.30
|
| Rate for Payer: EPIC Health Plan Senior |
$182.30
|
| Rate for Payer: Galaxy Health WC |
$387.40
|
| Rate for Payer: Global Benefits Group Commercial |
$273.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$268.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$319.03
|
| Rate for Payer: Multiplan Commercial |
$341.82
|
| Rate for Payer: Networks By Design Commercial |
$296.24
|
| Rate for Payer: Prime Health Services Commercial |
$387.40
|
| Rate for Payer: Riverside University Health System MISP |
$182.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$273.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$273.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$227.88
|
| Rate for Payer: United Healthcare All Other HMO |
$227.88
|
| Rate for Payer: United Healthcare HMO Rider |
$227.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$227.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$387.40
|
| Rate for Payer: Vantage Medical Group Senior |
$387.40
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
IP
|
$455.76
|
|
|
Service Code
|
NDC 6738642201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.15 |
| Max. Negotiated Rate |
$410.18 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Blue Shield of California Commercial |
$365.52
|
| Rate for Payer: Blue Shield of California EPN |
$229.70
|
| Rate for Payer: Cash Price |
$205.09
|
| Rate for Payer: Central Health Plan Commercial |
$364.61
|
| Rate for Payer: Cigna of CA HMO |
$319.03
|
| Rate for Payer: Cigna of CA PPO |
$319.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$319.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$182.30
|
| Rate for Payer: EPIC Health Plan Senior |
$182.30
|
| Rate for Payer: Galaxy Health WC |
$387.40
|
| Rate for Payer: Global Benefits Group Commercial |
$273.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$410.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$289.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$268.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.15
|
| Rate for Payer: Multiplan Commercial |
$341.82
|
| Rate for Payer: Networks By Design Commercial |
$296.24
|
| Rate for Payer: Prime Health Services Commercial |
$387.40
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Central Health Plan Commercial |
$3.33
|
| Rate for Payer: Cigna of CA HMO |
$2.91
|
| Rate for Payer: Cigna of CA PPO |
$2.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: EPIC Health Plan Senior |
$1.66
|
| Rate for Payer: Galaxy Health WC |
$3.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$3.12
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$3.54
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Central Health Plan Commercial |
$3.33
|
| Rate for Payer: Cigna of CA HMO |
$2.91
|
| Rate for Payer: Cigna of CA PPO |
$2.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: EPIC Health Plan Senior |
$1.66
|
| Rate for Payer: Galaxy Health WC |
$3.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.91
|
| Rate for Payer: Multiplan Commercial |
$3.12
|
| Rate for Payer: Networks By Design Commercial |
$2.70
|
| Rate for Payer: Prime Health Services Commercial |
$3.54
|
| Rate for Payer: Riverside University Health System MISP |
$1.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.08
|
| Rate for Payer: United Healthcare All Other HMO |
$2.08
|
| Rate for Payer: United Healthcare HMO Rider |
$2.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.54
|
| Rate for Payer: Vantage Medical Group Senior |
$3.54
|
|
