|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
1710970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Senior |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.24
|
| Rate for Payer: TriValley Medical Group Senior |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
1710970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0041-37
|
| Hospital Charge Code |
1710961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Senior |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.24
|
| Rate for Payer: TriValley Medical Group Senior |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0041-37
|
| Hospital Charge Code |
1710961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 67877-146-05
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 67877-146-01
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65162-556-10
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 0228-2076-10
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 67877-146-01
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 65162-556-10
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 0228-2076-10
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 67877-146-05
|
| Hospital Charge Code |
1730140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 30 MG CAPSULE [7754]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0378-5050-01
|
| Hospital Charge Code |
1730141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TEMAZEPAM 30 MG CAPSULE [7754]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0378-5050-01
|
| Hospital Charge Code |
1730141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
TEMAZEPAM 7.5 MG CAPSULE [11500]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 0904-6436-04
|
| Hospital Charge Code |
1730166
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
TEMAZEPAM 7.5 MG CAPSULE [11500]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 0904-6436-04
|
| Hospital Charge Code |
1730166
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
TEMOZOLOMIDE 100 MG INTRAVENOUS SOLUTION [97260]
|
Facility
|
IP
|
$1,203.73
|
|
|
Service Code
|
CPT J9328
|
| Hospital Charge Code |
1755760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.88 |
| Max. Negotiated Rate |
$902.80 |
| Rate for Payer: Adventist Health Commercial |
$240.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$826.96
|
| Rate for Payer: Cash Price |
$541.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$553.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$650.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$814.93
|
| Rate for Payer: Heritage Provider Network Senior |
$814.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.93
|
| Rate for Payer: Multiplan Commercial |
$902.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$438.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$402.17
|
|
|
TEMOZOLOMIDE 100 MG INTRAVENOUS SOLUTION [97260]
|
Facility
|
OP
|
$1,203.73
|
|
|
Service Code
|
CPT J9328
|
| Hospital Charge Code |
1755760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$902.80 |
| Rate for Payer: Adventist Health Commercial |
$240.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$826.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.11
|
| Rate for Payer: Blue Shield of California Commercial |
$10.23
|
| Rate for Payer: Blue Shield of California EPN |
$10.23
|
| Rate for Payer: Cash Price |
$541.68
|
| Rate for Payer: Cash Price |
$541.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$553.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.44
|
| Rate for Payer: Dignity Health Senior |
$11.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$770.39
|
| Rate for Payer: EPIC Health Plan Medicare |
$10.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$557.33
|
| Rate for Payer: Heritage Provider Network Senior |
$557.33
|
| Rate for Payer: Humana Medicare |
$10.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.11
|
| Rate for Payer: Multiplan Commercial |
$902.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$481.49
|
| Rate for Payer: TriValley Medical Group Senior |
$481.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$438.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$402.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Vantage Medical Group Senior |
$10.40
|
|
|
TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]
|
Facility
|
IP
|
$26.03
|
|
|
Service Code
|
CPT J8700
|
| Hospital Charge Code |
1715241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$19.52 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.88
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.62
|
| Rate for Payer: Heritage Provider Network Senior |
$17.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$19.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.70
|
|
|
TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]
|
Facility
|
OP
|
$26.03
|
|
|
Service Code
|
CPT J8700
|
| Hospital Charge Code |
1715241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.37
|
| Rate for Payer: Blue Shield of California Commercial |
$2.71
|
| Rate for Payer: Blue Shield of California EPN |
$2.71
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.13
|
| Rate for Payer: Dignity Health Senior |
$22.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.05
|
| Rate for Payer: Heritage Provider Network Senior |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.51
|
| Rate for Payer: Multiplan Commercial |
$19.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.41
|
| Rate for Payer: TriValley Medical Group Senior |
$10.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.13
|
| Rate for Payer: Vantage Medical Group Senior |
$22.13
|
|
|
Temporary closure of eyelids by suture (eg, Frost suture)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 67875
|
| Min. Negotiated Rate |
$328.72 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,897.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,391.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,264.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,897.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,391.47
|
| Rate for Payer: Dignity Health Senior |
$1,264.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,264.97
|
| Rate for Payer: Humana Medicare |
$1,264.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$328.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,264.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,403.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,492.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,593.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,593.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,391.47
|
| Rate for Payer: TriValley Medical Group Senior |
$1,264.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,897.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,391.47
|
| Rate for Payer: Vantage Medical Group Senior |
$1,264.97
|
|
|
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN [82228]
|
Facility
|
IP
|
$1,547.87
|
|
|
Service Code
|
CPT J9330
|
| Hospital Charge Code |
1720968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$280.16 |
| Max. Negotiated Rate |
$1,160.90 |
| Rate for Payer: Adventist Health Commercial |
$309.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,063.39
|
| Rate for Payer: Cash Price |
$696.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$712.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$835.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,047.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1,047.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$280.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$386.97
|
| Rate for Payer: Multiplan Commercial |
$1,160.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$564.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$517.14
|
|
|
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN [82228]
|
Facility
|
OP
|
$1,547.87
|
|
|
Service Code
|
CPT J9330
|
| Hospital Charge Code |
1720968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.99 |
| Max. Negotiated Rate |
$1,160.90 |
| Rate for Payer: Adventist Health Commercial |
$309.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$76.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,063.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$102.64
|
| Rate for Payer: Blue Shield of California Commercial |
$51.13
|
| Rate for Payer: Blue Shield of California EPN |
$51.13
|
| Rate for Payer: Cash Price |
$696.54
|
| Rate for Payer: Cash Price |
$696.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$712.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.09
|
| Rate for Payer: Dignity Health Senior |
$34.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$990.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$716.66
|
| Rate for Payer: Heritage Provider Network Senior |
$716.66
|
| Rate for Payer: Humana Medicare |
$30.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$55.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$280.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$386.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.05
|
| Rate for Payer: Multiplan Commercial |
$1,160.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$619.15
|
| Rate for Payer: TriValley Medical Group Senior |
$619.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$564.35
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$517.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.09
|
| Rate for Payer: Vantage Medical Group Senior |
$30.99
|
|
|
TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES
|
Facility
|
IP
|
$8,404.88
|
|
|
Service Code
|
APR-DRG 3171
|
| Min. Negotiated Rate |
$8,404.88 |
| Max. Negotiated Rate |
$8,404.88 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,404.88
|
|
|
TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES
|
Facility
|
IP
|
$10,871.23
|
|
|
Service Code
|
APR-DRG 3172
|
| Min. Negotiated Rate |
$10,871.23 |
| Max. Negotiated Rate |
$10,871.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,871.23
|
|
