|
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
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$13.35 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.78
|
| Rate for Payer: Blue Shield of California Commercial |
$9.58
|
| Rate for Payer: Blue Shield of California EPN |
$7.66
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.35
|
| Rate for Payer: Dignity Health Senior |
$13.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.72
|
| Rate for Payer: Heritage Provider Network Senior |
$9.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.99
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.99
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.28
|
| Rate for Payer: TriValley Medical Group Senior |
$6.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Vantage Medical Group Senior |
$13.35
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$11.78 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.63
|
| Rate for Payer: Heritage Provider Network Senior |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.07
|
| Rate for Payer: Blue Shield of California Commercial |
$5.75
|
| Rate for Payer: Blue Shield of California EPN |
$4.60
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.01
|
| Rate for Payer: Dignity Health Senior |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Senior |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.59
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.77
|
| Rate for Payer: TriValley Medical Group Senior |
$3.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$8.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: Dignity Health Senior |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Senior |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$7.07 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.38
|
| Rate for Payer: Heritage Provider Network Senior |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.35
|
| Rate for Payer: Multiplan Commercial |
$7.07
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 69452-117-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.21
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
IP
|
$455.76
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$341.82 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Cash Price |
$250.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$246.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.55
|
| Rate for Payer: Heritage Provider Network Senior |
$308.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.94
|
| Rate for Payer: Multiplan Commercial |
$341.82
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
|
OP
|
$455.76
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.49 |
| Max. Negotiated Rate |
$387.40 |
| Rate for Payer: Adventist Health Commercial |
$91.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$243.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$313.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$250.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$341.82
|
| Rate for Payer: Blue Shield of California Commercial |
$278.01
|
| Rate for Payer: Blue Shield of California EPN |
$222.41
|
| Rate for Payer: Cash Price |
$250.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$296.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$387.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$387.40
|
| Rate for Payer: Dignity Health Senior |
$387.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$291.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$282.12
|
| Rate for Payer: Heritage Provider Network Senior |
$282.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$217.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$319.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$319.03
|
| Rate for Payer: Multiplan Commercial |
$341.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$182.30
|
| Rate for Payer: TriValley Medical Group Senior |
$182.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$227.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$227.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$387.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$387.40
|
| Rate for Payer: Vantage Medical Group Senior |
$387.40
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$4.39
|
| Rate for Payer: Blue Shield of California EPN |
$3.51
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Senior |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.46
|
| Rate for Payer: Heritage Provider Network Senior |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.04
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Senior |
$2.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.12
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Adventist Health Commercial |
$0.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.12
|
| Rate for Payer: Blue Shield of California Commercial |
$2.54
|
| Rate for Payer: Blue Shield of California EPN |
$2.03
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.54
|
| Rate for Payer: Dignity Health Senior |
$3.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.58
|
| Rate for Payer: Heritage Provider Network Senior |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.91
|
| Rate for Payer: Multiplan Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.66
|
| Rate for Payer: TriValley Medical Group Senior |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.54
|
| Rate for Payer: Vantage Medical Group Senior |
$3.54
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Senior |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 60219-1523-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.52
|
| Rate for Payer: Dignity Health Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Senior |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.18
|
| Rate for Payer: TriValley Medical Group Senior |
$1.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.52
|
| Rate for Payer: Vantage Medical Group Senior |
$2.52
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 60219-1523-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Adventist Health Commercial |
$0.59
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.00
|
| Rate for Payer: Heritage Provider Network Senior |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.73
|
| Rate for Payer: Dignity Health Senior |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Senior |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$1.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.35
|
| Rate for Payer: Dignity Health Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
IP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$71.12 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.20
|
| Rate for Payer: Heritage Provider Network Senior |
$64.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.71
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.40
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
|
OP
|
$94.83
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$80.61 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$71.12
|
| Rate for Payer: Blue Shield of California Commercial |
$57.85
|
| Rate for Payer: Blue Shield of California EPN |
$46.28
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$80.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$80.61
|
| Rate for Payer: Dignity Health Senior |
$80.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.70
|
| Rate for Payer: Heritage Provider Network Senior |
$58.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$43.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$45.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$66.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$66.38
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$80.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$80.61
|
| Rate for Payer: Vantage Medical Group Senior |
$80.61
|
|
