|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$779.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.80 |
| Max. Negotiated Rate |
$701.10 |
| Rate for Payer: Adventist Health Commercial |
$155.80
|
| Rate for Payer: Blue Shield of California Commercial |
$602.17
|
| Rate for Payer: Blue Shield of California EPN |
$392.62
|
| Rate for Payer: Cash Price |
$428.45
|
| Rate for Payer: Central Health Plan Commercial |
$623.20
|
| Rate for Payer: Cigna of CA HMO |
$545.30
|
| Rate for Payer: Cigna of CA PPO |
$545.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$311.60
|
| Rate for Payer: EPIC Health Plan Senior |
$311.60
|
| Rate for Payer: Galaxy Health WC |
$662.15
|
| Rate for Payer: Global Benefits Group Commercial |
$467.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$701.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$519.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$296.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$482.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$155.80
|
| Rate for Payer: Multiplan Commercial |
$584.25
|
| Rate for Payer: Networks By Design Commercial |
$389.50
|
| Rate for Payer: Prime Health Services Commercial |
$662.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$292.36
|
| Rate for Payer: United Healthcare All Other HMO |
$284.57
|
| Rate for Payer: United Healthcare HMO Rider |
$278.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$255.12
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.48 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.53
|
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$3.76
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Central Health Plan Commercial |
$7.54
|
| Rate for Payer: Cigna of CA HMO |
$6.59
|
| Rate for Payer: Cigna of CA PPO |
$6.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Senior |
$3.77
|
| Rate for Payer: Galaxy Health WC |
$8.01
|
| Rate for Payer: Global Benefits Group Commercial |
$5.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.48
|
| Rate for Payer: InnovAge PACE Commercial |
$4.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.59
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
| Rate for Payer: Networks By Design Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$8.01
|
| Rate for Payer: Riverside University Health System MISP |
$3.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Other HMO |
$4.71
|
| Rate for Payer: United Healthcare HMO Rider |
$4.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.48 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$4.75
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Central Health Plan Commercial |
$7.54
|
| Rate for Payer: Cigna of CA HMO |
$6.59
|
| Rate for Payer: Cigna of CA PPO |
$6.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Senior |
$3.77
|
| Rate for Payer: Galaxy Health WC |
$8.01
|
| Rate for Payer: Global Benefits Group Commercial |
$5.65
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
| Rate for Payer: Networks By Design Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| 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 |
$9.22
|
| Rate for Payer: Blue Shield of California Commercial |
$9.59
|
| Rate for Payer: Blue Shield of California EPN |
$6.26
|
| Rate for Payer: Cash Price |
$8.63
|
| 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: 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: InnovAge PACE Commercial |
$7.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.99
|
| Rate for Payer: Molina Healthcare of CA 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
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| 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 |
$12.14
|
| Rate for Payer: Blue Shield of California EPN |
$7.91
|
| Rate for Payer: Cash Price |
$8.63
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$10.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.72
|
| 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 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| 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 |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.88
|
| 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: 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: InnovAge PACE Commercial |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA 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
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| 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 |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$0.88
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.00
|
| 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 25 MG TABLET [92777]
|
Facility
|
OP
|
$455.76
|
|
|
Service Code
|
NDC 67386-422-01
|
| 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 |
$267.67
|
| Rate for Payer: Blue Shield of California Commercial |
$278.47
|
| Rate for Payer: Blue Shield of California EPN |
$181.85
|
| Rate for Payer: Cash Price |
$250.67
|
| 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: 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: InnovAge PACE Commercial |
$227.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$303.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$282.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$319.03
|
| Rate for Payer: Molina Healthcare of CA 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 67386-422-01
|
| 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 |
$352.30
|
| Rate for Payer: Blue Shield of California EPN |
$229.70
|
| Rate for Payer: Cash Price |
$250.67
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$303.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$173.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$282.12
|
| 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 0.5 % EYE DROPS [7795]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.23
|
| Rate for Payer: Blue Shield of California Commercial |
$4.40
|
| Rate for Payer: Blue Shield of California EPN |
$2.87
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Central Health Plan Commercial |
$5.76
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.48
|
| Rate for Payer: InnovAge PACE Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
| Rate for Payer: Riverside University Health System MISP |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO |
$3.60
|
| Rate for Payer: United Healthcare HMO Rider |
$3.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$5.57
|
| Rate for Payer: Blue Shield of California EPN |
$3.63
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Central Health Plan Commercial |
$5.76
|
| Rate for Payer: Cigna of CA HMO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: EPIC Health Plan Senior |
$2.88
|
| Rate for Payer: Galaxy Health WC |
$6.12
|
| Rate for Payer: Global Benefits Group Commercial |
$4.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Networks By Design Commercial |
$4.68
|
| Rate for Payer: Prime Health Services Commercial |
$6.12
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0065-0741-14
|
| 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 |
$3.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$2.29
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$2.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.58
|
| 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 0065-0741-14
|
| 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 |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.54
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$2.29
|
| 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: 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: InnovAge PACE Commercial |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.91
|
| Rate for Payer: Molina Healthcare of CA 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
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 60219-1523-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Central Health Plan Commercial |
$2.37
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.66
|
| Rate for Payer: InnovAge PACE Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
| Rate for Payer: Riverside University Health System MISP |
$1.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.48
|
| Rate for Payer: United Healthcare All Other HMO |
$1.48
|
| Rate for Payer: United Healthcare HMO Rider |
$1.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$1.58
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.81
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Central Health Plan Commercial |
$1.63
|
| Rate for Payer: Cigna of CA HMO |
$1.43
|
| Rate for Payer: Cigna of CA PPO |
$1.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: EPIC Health Plan Senior |
$0.82
|
| Rate for Payer: Galaxy Health WC |
$1.73
|
| Rate for Payer: Global Benefits Group Commercial |
$1.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.84
|
| Rate for Payer: InnovAge PACE Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: Networks By Design Commercial |
$1.33
|
| Rate for Payer: Prime Health Services Commercial |
$1.73
|
| Rate for Payer: Riverside University Health System MISP |
$0.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: InnovAge PACE Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Riverside University Health System MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: InnovAge PACE Commercial |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
| Rate for Payer: Riverside University Health System MISP |
$1.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1.97
|
| Rate for Payer: United Healthcare HMO Rider |
$1.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.55 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Central Health Plan Commercial |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$2.76
|
| Rate for Payer: Cigna of CA PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Networks By Design Commercial |
$2.56
|
| Rate for Payer: Prime Health Services Commercial |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 60219-1523-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.49
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Central Health Plan Commercial |
$2.37
|
| Rate for Payer: Cigna of CA HMO |
$2.07
|
| Rate for Payer: Cigna of CA PPO |
$2.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: EPIC Health Plan Senior |
$1.18
|
| Rate for Payer: Galaxy Health WC |
$2.52
|
| Rate for Payer: Global Benefits Group Commercial |
$1.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: Networks By Design Commercial |
$1.92
|
| Rate for Payer: Prime Health Services Commercial |
$2.52
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: InnovAge PACE Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$45.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.69
|
| Rate for Payer: Blue Shield of California Commercial |
$57.56
|
| Rate for Payer: Blue Shield of California EPN |
$37.65
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: Cigna of CA HMO |
$60.69
|
| Rate for Payer: Cigna of CA PPO |
$70.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$45.72
|
| Rate for Payer: InnovAge PACE Commercial |
$47.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$50.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$58.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$66.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: Riverside University Health System MISP |
$37.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$56.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$56.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$85.35 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Blue Shield of California Commercial |
$73.30
|
| Rate for Payer: Blue Shield of California EPN |
$47.79
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Central Health Plan Commercial |
$75.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$37.93
|
| Rate for Payer: EPIC Health Plan Senior |
$37.93
|
| Rate for Payer: Galaxy Health WC |
$80.61
|
| Rate for Payer: Global Benefits Group Commercial |
$56.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$85.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$63.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$58.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: Networks By Design Commercial |
$61.64
|
| Rate for Payer: Prime Health Services Commercial |
$80.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$35.59
|
| Rate for Payer: United Healthcare All Other HMO |
$34.64
|
| Rate for Payer: United Healthcare HMO Rider |
$33.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.06
|
|
