|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
1711328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$2.00
|
| 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 2.5 MG TABLET [11508]
|
Facility
OP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
1711328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.08
|
| Rate for Payer: BCBS Transplant Transplant |
$3.13
|
| Rate for Payer: Blue Shield of California Commercial |
$3.28
|
| Rate for Payer: Blue Shield of California EPN |
$2.55
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Central Health Plan Commercial |
$4.18
|
| Rate for Payer: Cigna of CA HMO |
$3.65
|
| Rate for Payer: Cigna of CA PPO |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.09
|
| Rate for Payer: Galaxy Health WC |
$4.44
|
| Rate for Payer: Global Benefits Group Commercial |
$3.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.92
|
| Rate for Payer: IEHP medi-cal |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Networks By Design Commercial |
$3.39
|
| Rate for Payer: Prime Health Services Commercial |
$4.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.13
|
| Rate for Payer: Riverside University Health MISP |
$2.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.61
|
| Rate for Payer: United Healthcare All Other HMO |
$2.61
|
| Rate for Payer: United Healthcare HMO Rider |
$2.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.44
|
| Rate for Payer: Vantage Medical Group Senior |
$4.44
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
1711328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.77
|
| Rate for Payer: BCBS Transplant Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| 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: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$2.25
|
| Rate for Payer: IEHP medi-cal |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: Riverside University Health MISP |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.60
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$2.00
|
| 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
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Blue Shield of California Commercial |
$4.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.41
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Central Health Plan Commercial |
$5.10
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: Galaxy Health WC |
$5.42
|
| Rate for Payer: Global Benefits Group Commercial |
$3.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$4.78
|
| Rate for Payer: Networks By Design Commercial |
$4.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.42
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
OP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.77
|
| Rate for Payer: BCBS Transplant Transplant |
$3.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Central Health Plan Commercial |
$5.10
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.55
|
| Rate for Payer: Galaxy Health WC |
$5.42
|
| Rate for Payer: Global Benefits Group Commercial |
$3.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.78
|
| Rate for Payer: IEHP medi-cal |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$4.78
|
| Rate for Payer: Networks By Design Commercial |
$4.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.42
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.83
|
| Rate for Payer: Riverside University Health MISP |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.19
|
| Rate for Payer: United Healthcare All Other HMO |
$3.19
|
| Rate for Payer: United Healthcare HMO Rider |
$3.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: Vantage Medical Group Senior |
$5.42
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
1712001
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.77
|
| Rate for Payer: BCBS Transplant Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| 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: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$2.25
|
| Rate for Payer: IEHP medi-cal |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: Riverside University Health MISP |
$1.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
OP
|
$1,140.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX235956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$1,026.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$692.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$969.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$627.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$627.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$551.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$673.51
|
| Rate for Payer: BCBS Transplant Transplant |
$684.00
|
| Rate for Payer: Blue Shield of California Commercial |
$717.06
|
| Rate for Payer: Blue Shield of California EPN |
$557.46
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Central Health Plan Commercial |
$912.00
|
| Rate for Payer: Cigna of CA HMO |
$798.00
|
| Rate for Payer: Cigna of CA PPO |
$798.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$969.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$456.00
|
| Rate for Payer: Galaxy Health WC |
$969.00
|
| Rate for Payer: Global Benefits Group Commercial |
$684.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,026.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$855.00
|
| Rate for Payer: IEHP medi-cal |
$399.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$760.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.00
|
| Rate for Payer: Multiplan Commercial |
$855.00
|
| Rate for Payer: Networks By Design Commercial |
$570.00
|
| Rate for Payer: Prime Health Services Commercial |
$969.00
|
| Rate for Payer: Riverside University Health MISP |
$456.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$684.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$684.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$570.00
|
| Rate for Payer: United Healthcare All Other HMO |
$570.00
|
| Rate for Payer: United Healthcare HMO Rider |
$570.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$570.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$969.00
|
| Rate for Payer: Vantage Medical Group Senior |
$969.00
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
IP
|
$1,140.00
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
ERX235956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$1,026.00 |
| Rate for Payer: Blue Shield of California Commercial |
$855.00
|
| Rate for Payer: Blue Shield of California EPN |
$608.76
|
| Rate for Payer: Cash Price |
$513.00
|
| Rate for Payer: Central Health Plan Commercial |
$912.00
|
| Rate for Payer: Cigna of CA HMO |
$798.00
|
| Rate for Payer: Cigna of CA PPO |
$798.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$456.00
|
| Rate for Payer: Galaxy Health WC |
$969.00
|
| Rate for Payer: Global Benefits Group Commercial |
$684.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,026.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$760.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.00
|
| Rate for Payer: Multiplan Commercial |
$855.00
|
| Rate for Payer: Networks By Design Commercial |
$570.00
|
| Rate for Payer: Prime Health Services Commercial |
$969.00
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
IP
|
$9.26
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1720036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: Blue Shield of California Commercial |
$6.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.94
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Central Health Plan Commercial |
$7.41
|
| Rate for Payer: Cigna of CA HMO |
$6.48
|
| Rate for Payer: Cigna of CA PPO |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.70
|
| Rate for Payer: Galaxy Health WC |
$7.87
|
| Rate for Payer: Global Benefits Group Commercial |
$5.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$6.94
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$7.87
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
OP
|
$9.26
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1720036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: BCBS Transplant Transplant |
$5.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Central Health Plan Commercial |
$7.41
|
| Rate for Payer: Cigna of CA HMO |
$6.48
|
| Rate for Payer: Cigna of CA PPO |
$6.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.70
|
| Rate for Payer: Galaxy Health WC |
$7.87
|
| Rate for Payer: Global Benefits Group Commercial |
$5.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.94
|
| Rate for Payer: IEHP medi-cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$6.94
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$7.87
|
| Rate for Payer: Riverside University Health MISP |
$3.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Other HMO |
$4.63
|
| Rate for Payer: United Healthcare HMO Rider |
$4.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.87
|
| Rate for Payer: Vantage Medical Group Senior |
$7.87
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
OP
|
$22.25
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1790026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: BCBS Transplant Transplant |
$13.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| 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 |
$15.58
|
| Rate for Payer: Cigna of CA PPO |
$15.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$16.69
|
| Rate for Payer: IEHP medi-cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.84
|
| 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: Riverside University Health 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 |
$11.12
|
| Rate for Payer: United Healthcare All Other HMO |
$11.12
|
| Rate for Payer: United Healthcare HMO Rider |
$11.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.91
|
| Rate for Payer: Vantage Medical Group Senior |
$18.91
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
IP
|
$22.25
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
1790026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Blue Shield of California Commercial |
$16.69
|
| Rate for Payer: Blue Shield of California EPN |
$11.88
|
| Rate for Payer: Cash Price |
$10.01
|
| Rate for Payer: Central Health Plan Commercial |
$17.80
|
| Rate for Payer: Cigna of CA HMO |
$15.58
|
| Rate for Payer: Cigna of CA PPO |
$15.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$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 Permanente of CA Commercial/Self Funded |
$14.84
|
| 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
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
OP
|
$91.77
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
1721039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$186.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$186.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$78.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$50.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$50.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$40.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.12
|
| Rate for Payer: BCBS Transplant Transplant |
$55.06
|
| Rate for Payer: Blue Shield of California Commercial |
$34.16
|
| Rate for Payer: Blue Shield of California EPN |
$31.06
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Central Health Plan Commercial |
$73.42
|
| Rate for Payer: Cigna of CA HMO |
$64.24
|
| Rate for Payer: Cigna of CA PPO |
$64.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$78.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.71
|
| Rate for Payer: Galaxy Health WC |
$78.00
|
| Rate for Payer: Global Benefits Group Commercial |
$55.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$82.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$68.83
|
| Rate for Payer: IEHP medi-cal |
$27.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.35
|
| Rate for Payer: Multiplan Commercial |
$68.83
|
| Rate for Payer: Networks By Design Commercial |
$45.88
|
| Rate for Payer: Prime Health Services Commercial |
$78.00
|
| Rate for Payer: Riverside University Health MISP |
$36.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.88
|
| Rate for Payer: United Healthcare All Other HMO |
$45.88
|
| Rate for Payer: United Healthcare HMO Rider |
$45.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$78.00
|
| Rate for Payer: Vantage Medical Group Senior |
$78.00
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
IP
|
$91.77
|
|
|
Service Code
|
CPT 90714
|
| Hospital Charge Code |
1721039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$82.59 |
| Rate for Payer: Blue Shield of California Commercial |
$68.83
|
| Rate for Payer: Blue Shield of California EPN |
$49.01
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Central Health Plan Commercial |
$73.42
|
| Rate for Payer: Cigna of CA HMO |
$64.24
|
| Rate for Payer: Cigna of CA PPO |
$64.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.71
|
| Rate for Payer: Galaxy Health WC |
$78.00
|
| Rate for Payer: Global Benefits Group Commercial |
$55.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$82.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.35
|
| Rate for Payer: Multiplan Commercial |
$68.83
|
| Rate for Payer: Networks By Design Commercial |
$45.88
|
| Rate for Payer: Prime Health Services Commercial |
$78.00
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
IP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$60.44 |
| Rate for Payer: Blue Shield of California Commercial |
$50.37
|
| Rate for Payer: Blue Shield of California EPN |
$35.86
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Central Health Plan Commercial |
$53.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.86
|
| Rate for Payer: Galaxy Health WC |
$57.09
|
| Rate for Payer: Global Benefits Group Commercial |
$40.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$60.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.43
|
| Rate for Payer: Multiplan Commercial |
$50.37
|
| Rate for Payer: Networks By Design Commercial |
$43.65
|
| Rate for Payer: Prime Health Services Commercial |
$57.09
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
OP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$60.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$40.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$57.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$32.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.68
|
| Rate for Payer: BCBS Transplant Transplant |
$40.30
|
| Rate for Payer: Blue Shield of California Commercial |
$42.24
|
| Rate for Payer: Blue Shield of California EPN |
$32.84
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Central Health Plan Commercial |
$53.73
|
| Rate for Payer: Cigna of CA HMO |
$42.98
|
| Rate for Payer: Cigna of CA PPO |
$49.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$26.86
|
| Rate for Payer: Galaxy Health WC |
$57.09
|
| Rate for Payer: Global Benefits Group Commercial |
$40.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$60.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$50.37
|
| Rate for Payer: IEHP medi-cal |
$23.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$44.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.43
|
| Rate for Payer: Multiplan Commercial |
$50.37
|
| Rate for Payer: Networks By Design Commercial |
$43.65
|
| Rate for Payer: Prime Health Services Commercial |
$57.09
|
| Rate for Payer: Riverside University Health MISP |
$26.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.58
|
| Rate for Payer: United Healthcare All Other HMO |
$33.58
|
| Rate for Payer: United Healthcare HMO Rider |
$33.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.09
|
| Rate for Payer: Vantage Medical Group Senior |
$57.09
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
OP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.26 |
| Max. Negotiated Rate |
$3,585.70 |
| Rate for Payer: Adventist Health Medi-Cal |
$578.61
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3,585.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$723.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$636.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$197.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$216.71
|
| Rate for Payer: BCBS Transplant Transplant |
$453.79
|
| Rate for Payer: Blue Shield of California Commercial |
$734.45
|
| Rate for Payer: Blue Shield of California EPN |
$667.68
|
| Rate for Payer: Caremore Medicare Advantage |
$578.61
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Central Health Plan Commercial |
$605.05
|
| Rate for Payer: Cigna of CA HMO |
$529.42
|
| Rate for Payer: Cigna of CA PPO |
$529.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$867.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$781.13
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$578.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$578.61
|
| Rate for Payer: Galaxy Health WC |
$642.86
|
| Rate for Payer: Global Benefits Group Commercial |
$453.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$680.68
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$567.23
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$948.93
|
| Rate for Payer: IEHP medi-cal |
$954.71
|
| Rate for Payer: IEHP Medicare Advantage |
$578.61
|
| Rate for Payer: Innovage PACE Commercial |
$867.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$578.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$775.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$775.34
|
| Rate for Payer: Multiplan Commercial |
$567.23
|
| Rate for Payer: Networks By Design Commercial |
$378.16
|
| Rate for Payer: Prime Health Services Commercial |
$642.86
|
| Rate for Payer: Prime Health Services Medicare |
$613.33
|
| Rate for Payer: Riverside University Health MISP |
$636.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$453.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$453.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$378.16
|
| Rate for Payer: United Healthcare All Other HMO |
$378.16
|
| Rate for Payer: United Healthcare HMO Rider |
$378.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$378.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$867.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: Vantage Medical Group Senior |
$578.61
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
IP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.26 |
| Max. Negotiated Rate |
$680.68 |
| Rate for Payer: Blue Shield of California Commercial |
$567.23
|
| Rate for Payer: Blue Shield of California EPN |
$403.87
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Central Health Plan Commercial |
$605.05
|
| Rate for Payer: Cigna of CA HMO |
$529.42
|
| Rate for Payer: Cigna of CA PPO |
$529.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$302.52
|
| Rate for Payer: Galaxy Health WC |
$642.86
|
| Rate for Payer: Global Benefits Group Commercial |
$453.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$680.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.26
|
| Rate for Payer: Multiplan Commercial |
$567.23
|
| Rate for Payer: Networks By Design Commercial |
$378.16
|
| Rate for Payer: Prime Health Services Commercial |
$642.86
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.48 |
| Rate for Payer: Blue Shield of California Commercial |
$7.06
|
| Rate for Payer: Blue Shield of California EPN |
$5.03
|
| Rate for Payer: Cash Price |
$4.24
|
| 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: 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: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
| 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
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$8.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.57
|
| Rate for Payer: BCBS Transplant Transplant |
$5.65
|
| Rate for Payer: Blue Shield of California Commercial |
$5.93
|
| Rate for Payer: Blue Shield of California EPN |
$4.61
|
| Rate for Payer: Cash Price |
$4.24
|
| 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: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$7.06
|
| Rate for Payer: IEHP medi-cal |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
| Rate for Payer: Networks By Design Commercial |
$6.12
|
| Rate for Payer: Prime Health Services Commercial |
$8.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.65
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
IP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Blue Shield of California Commercial |
$11.78
|
| Rate for Payer: Blue Shield of California EPN |
$8.38
|
| Rate for Payer: Cash Price |
$7.07
|
| 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: Galaxy Health WC |
$13.34
|
| 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: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
| Rate for Payer: Networks By Design Commercial |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$13.34
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.28
|
| Rate for Payer: BCBS Transplant Transplant |
$9.42
|
| Rate for Payer: Blue Shield of California Commercial |
$9.88
|
| Rate for Payer: Blue Shield of California EPN |
$7.68
|
| Rate for Payer: Cash Price |
$7.07
|
| 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 |
$13.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.28
|
| Rate for Payer: Galaxy Health WC |
$13.34
|
| Rate for Payer: Global Benefits Group Commercial |
$9.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.78
|
| Rate for Payer: IEHP medi-cal |
$5.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.47
|
| 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 |
$10.20
|
| Rate for Payer: Prime Health Services Commercial |
$13.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.42
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$13.34
|
| Rate for Payer: Vantage Medical Group Senior |
$13.34
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
OP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$357.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$241.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$337.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$218.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$218.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$192.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$234.84
|
| Rate for Payer: BCBS Transplant Transplant |
$238.49
|
| Rate for Payer: Blue Shield of California Commercial |
$250.02
|
| Rate for Payer: Blue Shield of California EPN |
$194.37
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: Central Health Plan Commercial |
$317.99
|
| Rate for Payer: Cigna of CA HMO |
$278.24
|
| Rate for Payer: Cigna of CA PPO |
$278.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$337.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$159.00
|
| Rate for Payer: Galaxy Health WC |
$337.87
|
| Rate for Payer: Global Benefits Group Commercial |
$238.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$357.74
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$298.12
|
| Rate for Payer: IEHP medi-cal |
$139.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$298.12
|
| Rate for Payer: Networks By Design Commercial |
$258.37
|
| Rate for Payer: Prime Health Services Commercial |
$337.87
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$238.49
|
| Rate for Payer: Riverside University Health MISP |
$159.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$238.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$238.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$198.74
|
| Rate for Payer: United Healthcare All Other HMO |
$198.74
|
| Rate for Payer: United Healthcare HMO Rider |
$198.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$198.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.87
|
| Rate for Payer: Vantage Medical Group Senior |
$337.87
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
IP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$357.74 |
| Rate for Payer: Blue Shield of California Commercial |
$298.12
|
| Rate for Payer: Blue Shield of California EPN |
$212.26
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: Central Health Plan Commercial |
$317.99
|
| Rate for Payer: Cigna of CA HMO |
$278.24
|
| Rate for Payer: Cigna of CA PPO |
$278.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$159.00
|
| Rate for Payer: Galaxy Health WC |
$337.87
|
| Rate for Payer: Global Benefits Group Commercial |
$238.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$357.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$265.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.50
|
| Rate for Payer: Multiplan Commercial |
$298.12
|
| Rate for Payer: Networks By Design Commercial |
$258.37
|
| Rate for Payer: Prime Health Services Commercial |
$337.87
|
|
