|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
|
OP
|
$103.88
|
|
|
Service Code
|
NDC 72607-100-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$88.30 |
| Rate for Payer: Adventist Health Commercial |
$20.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$55.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$88.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.91
|
| Rate for Payer: Blue Shield of California Commercial |
$63.37
|
| Rate for Payer: Blue Shield of California EPN |
$50.69
|
| Rate for Payer: Cash Price |
$57.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$88.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.30
|
| Rate for Payer: Dignity Health Senior |
$88.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.30
|
| Rate for Payer: Heritage Provider Network Senior |
$64.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$49.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$72.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$77.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.55
|
| Rate for Payer: TriValley Medical Group Senior |
$41.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$51.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$88.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.30
|
| Rate for Payer: Vantage Medical Group Senior |
$88.30
|
|
|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
|
IP
|
$103.88
|
|
|
Service Code
|
NDC 72607-100-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$77.91 |
| Rate for Payer: Adventist Health Commercial |
$20.78
|
| Rate for Payer: Cash Price |
$57.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.33
|
| Rate for Payer: Heritage Provider Network Senior |
$70.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.97
|
| Rate for Payer: Multiplan Commercial |
$77.91
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
|
OP
|
$819.41
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.38 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Adventist Health Commercial |
$163.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$437.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$562.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$41.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$36.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.27
|
| Rate for Payer: Blue Shield of California Commercial |
$32.38
|
| Rate for Payer: Blue Shield of California EPN |
$32.38
|
| Rate for Payer: Cash Price |
$450.68
|
| Rate for Payer: Cash Price |
$450.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$376.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$41.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.59
|
| Rate for Payer: Dignity Health Senior |
$36.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$524.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$33.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$379.39
|
| Rate for Payer: Heritage Provider Network Senior |
$379.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$33.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$390.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.92
|
| Rate for Payer: Multiplan Commercial |
$614.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$327.76
|
| Rate for Payer: TriValley Medical Group Senior |
$327.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$296.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$41.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.59
|
| Rate for Payer: Vantage Medical Group Senior |
$36.59
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
|
IP
|
$819.41
|
|
|
Service Code
|
HCPCS J9380
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$148.31 |
| Max. Negotiated Rate |
$614.56 |
| Rate for Payer: Adventist Health Commercial |
$163.88
|
| Rate for Payer: Cash Price |
$450.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$376.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$442.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$379.39
|
| Rate for Payer: Heritage Provider Network Senior |
$379.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.85
|
| Rate for Payer: Multiplan Commercial |
$614.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$296.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.31
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$3.09
|
| 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 40 MG TABLET [24335]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
901700029
|
|
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 |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.74
|
| Rate for Payer: Cash Price |
$3.09
|
| 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 |
$2.68
|
| 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: Molina Healthcare of CA Medi-Cal |
$3.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.93
|
| 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: United Healthcare All Other HMO/non HMO |
$2.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0041-37
|
| Hospital Charge Code |
901700029
|
|
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 |
$3.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.74
|
| Rate for Payer: Cash Price |
$3.09
|
| 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 |
$2.68
|
| 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: Molina Healthcare of CA Medi-Cal |
$3.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.93
|
| 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: United Healthcare All Other HMO/non HMO |
$2.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0041-37
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$3.09
|
| 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 0228-2076-10
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.06
|
| 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 0228-2076-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA 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 |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| 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: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 67877-146-05
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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
|
$0.10
|
|
|
Service Code
|
NDC 67877-146-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| 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: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 15 MG CAPSULE [7753]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 67877-146-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.06
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA 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 |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| 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: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
TEMAZEPAM 30 MG CAPSULE [7754]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0378-5050-01
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.08
|
| 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 |
901700029
|
|
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 |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| 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: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| 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 |
901700029
|
|
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: Cash Price |
$2.31
|
| 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 |
901700029
|
|
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 |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$2.31
|
| 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 |
$2.00
|
| 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: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| 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: United Healthcare All Other HMO/non HMO |
$2.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]
|
Facility
|
OP
|
$26.03
|
|
|
Service Code
|
HCPCS J8700
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$22.13 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.91
|
| 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 |
$6.86
|
| Rate for Payer: Blue Shield of California Commercial |
$2.70
|
| Rate for Payer: Blue Shield of California EPN |
$2.70
|
| Rate for Payer: Cash Price |
$14.32
|
| Rate for Payer: Cash Price |
$14.32
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.42
|
| 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: Molina Healthcare of CA Medi-Cal |
$18.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.22
|
| 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 |
$9.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.13
|
| Rate for Payer: Vantage Medical Group Senior |
$22.13
|
|
|
TEMOZOLOMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080346]
|
Facility
|
IP
|
$26.03
|
|
|
Service Code
|
HCPCS J8700
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$14.32
|
| 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 |
$12.05
|
| Rate for Payer: Heritage Provider Network Senior |
$12.05
|
| 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 |
$9.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.62
|
|
|
TENOFOVIR ALAFENAMIDE 25 MG TABLET [216415]
|
Facility
|
IP
|
$61.07
|
|
|
Service Code
|
NDC 61958-2301-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$45.80 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Cash Price |
$33.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.34
|
| Rate for Payer: Heritage Provider Network Senior |
$41.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
|
|
TENOFOVIR ALAFENAMIDE 25 MG TABLET [216415]
|
Facility
|
OP
|
$61.07
|
|
|
Service Code
|
NDC 61958-2301-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$51.91 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.80
|
| Rate for Payer: Blue Shield of California Commercial |
$37.25
|
| Rate for Payer: Blue Shield of California EPN |
$29.80
|
| Rate for Payer: Cash Price |
$33.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.91
|
| Rate for Payer: Dignity Health Senior |
$51.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.80
|
| Rate for Payer: Heritage Provider Network Senior |
$37.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$42.75
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.43
|
| Rate for Payer: TriValley Medical Group Senior |
$24.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.91
|
| Rate for Payer: Vantage Medical Group Senior |
$51.91
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 50268-758-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 50268-758-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.40
|
| Rate for Payer: Dignity Health Senior |
$2.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.40
|
| Rate for Payer: Vantage Medical Group Senior |
$2.40
|
|
|
TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET [31684]
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 50268-758-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.91
|
| Rate for Payer: Heritage Provider Network Senior |
$1.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
|
