|
TERBINAFINE HCL 250 MG TABLET [12724]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 65862-079-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
TERBINAFINE HCL 250 MG TABLET [12724]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 65862-079-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
TERBUTALINE 1 MG/ML CONTINUOUS INFUSION (STRAIGHT DRUG) [4080921]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$33.13 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.94
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$20.09
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.46
|
| Rate for Payer: TriValley Medical Group Senior |
$9.46
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$20.09
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
TERBUTALINE 1 MG/ML CONTINUOUS INFUSION (STRAIGHT DRUG) [4080921]
|
Facility
|
IP
|
$23.64
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.83
|
|
|
TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$33.13 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Blue Shield of California Commercial |
$14.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.34
|
| Rate for Payer: Blue Shield of California EPN |
$11.54
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.09
|
| Rate for Payer: Dignity Health Senior |
$20.09
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Senior |
$14.63
|
| Rate for Payer: Heritage Provider Network Senior |
$2.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$9.46
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$20.09
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
IP
|
$23.64
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.54
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.83
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
OP
|
$23.64
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$33.13 |
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$9.94
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$4.08
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$20.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Senior |
$0.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$9.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$20.09
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-132-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
OP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.18
|
| Rate for Payer: Blue Shield of California EPN |
$2.55
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.44
|
| Rate for Payer: Dignity Health Senior |
$4.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.23
|
| Rate for Payer: Heritage Provider Network Senior |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.65
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.44
|
| 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
|
IP
|
$5.22
|
|
|
Service Code
|
NDC 0527-1318-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.53
|
| Rate for Payer: Heritage Provider Network Senior |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| 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
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Senior |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 0527-1311-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Adventist Health Commercial |
$1.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.42
|
| Rate for Payer: Dignity Health Senior |
$5.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.95
|
| Rate for Payer: Heritage Provider Network Senior |
$3.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.55
|
| Rate for Payer: TriValley Medical Group Senior |
$2.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.42
|
| 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
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 24979-133-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 62559-722-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 62559-722-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.24
|
| Rate for Payer: Dignity Health Senior |
$1.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Senior |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Senior |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1.24
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$7.87 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Senior |
$4.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.47
|
|
|
TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL [7783]
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$8.92 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.92
|
| Rate for Payer: Dignity Health Senior |
$8.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Senior |
$4.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.34
|
| Rate for Payer: Multiplan Commercial |
$7.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.20
|
| Rate for Payer: TriValley Medical Group Senior |
$4.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.79
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.92
|
| Rate for Payer: Vantage Medical Group Senior |
$8.92
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$16.69 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.30
|
| Rate for Payer: Heritage Provider Network Senior |
$10.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.37
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [7784]
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.91
|
| Rate for Payer: Dignity Health Senior |
$18.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.30
|
| Rate for Payer: Heritage Provider Network Senior |
$10.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.57
|
| Rate for Payer: Multiplan Commercial |
$16.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.90
|
| Rate for Payer: TriValley Medical Group Senior |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.91
|
| Rate for Payer: Vantage Medical Group Senior |
$18.91
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
IP
|
$97.79
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$73.34 |
| Rate for Payer: Adventist Health Commercial |
$19.56
|
| Rate for Payer: Cash Price |
$53.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.28
|
| Rate for Payer: Heritage Provider Network Senior |
$45.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.45
|
| Rate for Payer: Multiplan Commercial |
$73.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.38
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
OP
|
$97.79
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$83.12 |
| Rate for Payer: Adventist Health Commercial |
$19.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$67.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.50
|
| Rate for Payer: Blue Shield of California Commercial |
$28.55
|
| Rate for Payer: Blue Shield of California EPN |
$28.55
|
| Rate for Payer: Cash Price |
$53.78
|
| Rate for Payer: Cash Price |
$53.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.12
|
| Rate for Payer: Dignity Health Senior |
$83.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.28
|
| Rate for Payer: Heritage Provider Network Senior |
$45.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$68.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$68.45
|
| Rate for Payer: Multiplan Commercial |
$73.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$39.12
|
| Rate for Payer: TriValley Medical Group Senior |
$39.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.12
|
| Rate for Payer: Vantage Medical Group Senior |
$83.12
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$779.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.00 |
| Max. Negotiated Rate |
$584.25 |
| Rate for Payer: Adventist Health Commercial |
$155.80
|
| Rate for Payer: Cash Price |
$428.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$358.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$360.68
|
| Rate for Payer: Heritage Provider Network Senior |
$360.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$141.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.75
|
| Rate for Payer: Multiplan Commercial |
$584.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$281.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$257.93
|
|
