|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 2438552403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 2438552405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 2438552405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 5167220801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 8770140472
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM [27023]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 8770140472
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
TERBINAFINE HCL 250 MG TABLET [12724]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 6586207930
|
| 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: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| 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 Foundation Hospitals 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 6586207930
|
| 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 Non-Gatekeeper |
$0.19
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| 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 |
$0.14
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
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: Aetna of CA Non-Gatekeeper |
$15.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| 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 |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| 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
|
| 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+ |
$7.83
|
|
|
TERBUTALINE 1 MG/ML CONTINUOUS INFUSION (STRAIGHT DRUG) [4080921]
|
Facility
|
OP
|
$23.64
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.09
|
| 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 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 |
$11.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.94
|
| 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: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| 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 |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| 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 |
$10.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.28
|
| 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/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.55
|
| 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 |
$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
|
| 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 |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$20.09
|
|
|
TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]
|
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: Aetna of CA Non-Gatekeeper |
$15.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| 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 |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$10.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| 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
|
| 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+ |
$7.83
|
|
|
TERBUTALINE 1 MG/ML MED NEB SOLUTION [192332]
|
Facility
|
OP
|
$23.64
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.09
|
| 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 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 |
$11.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.94
|
| 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: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$2.16
|
| 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 |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| 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 |
$10.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.28
|
| 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/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.55
|
| 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 |
$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
|
| 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 |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$20.09
|
|
|
TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION [11507]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cash Price |
$0.97
|
| 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: EPIC Health Plan Commercial |
$1.17
|
| 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 |
$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 Foundation Hospitals Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals 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: 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
|
$2.16
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$11.94 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Adventist Health Commercial |
$4.73
|
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.61
|
| 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 Commercial/Exchange |
$1.84
|
| 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 |
$1.62
|
| 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 |
$11.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.94
|
| 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 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 |
$10.64
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| 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 |
$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 |
$20.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.84
|
| 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 |
$10.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| 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 Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.39
|
| 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: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.55
|
| Rate for Payer: Multiplan Commercial |
$17.73
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$9.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.86
|
| 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 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+ |
$0.72
|
| 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 Commercial/Exchange |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.09
|
| 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
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 2497913201
|
| 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: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.35
|
| 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 Foundation Hospitals 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
|
$3.00
|
|
|
Service Code
|
NDC 2497913201
|
| 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 Non-Gatekeeper |
$1.85
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| 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 |
$1.35
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$5.22
|
|
|
Service Code
|
NDC 0527131801
|
| 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: Aetna of CA Non-Gatekeeper |
$3.36
|
| Rate for Payer: Cash Price |
$2.35
|
| 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 Foundation Hospitals Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
|
|
TERBUTALINE 2.5 MG TABLET [11508]
|
Facility
|
OP
|
$5.22
|
|
|
Service Code
|
NDC 0527131801
|
| 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 Non-Gatekeeper |
$3.23
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.61
|
| 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 |
$2.35
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5 MG TABLET [11509]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 2497913301
|
| 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 Non-Gatekeeper |
$1.85
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| 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 |
$1.35
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 0527131101
|
| 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 Non-Gatekeeper |
$3.94
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$3.19
|
| 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 |
$2.87
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$1.46
|
|
|
Service Code
|
NDC 6255972201
|
| 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: Aetna of CA Non-Gatekeeper |
$0.94
|
| Rate for Payer: Cash Price |
$0.66
|
| 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 Foundation Hospitals 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
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 2497913301
|
| 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: Aetna of CA Non-Gatekeeper |
$1.93
|
| Rate for Payer: Cash Price |
$1.35
|
| 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 Foundation Hospitals 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
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 6255972201
|
| 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 Non-Gatekeeper |
$0.90
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| 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 |
$0.66
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
TERBUTALINE 5 MG TABLET [11509]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 0527131101
|
| 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: Aetna of CA Non-Gatekeeper |
$4.11
|
| Rate for Payer: Cash Price |
$2.87
|
| 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 Foundation Hospitals Medi-Cal |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$4.79
|
|
|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
IP
|
$1,256.40
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.41 |
| Max. Negotiated Rate |
$942.30 |
| Rate for Payer: Adventist Health Commercial |
$251.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$809.12
|
| Rate for Payer: Cash Price |
$565.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$577.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$678.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$581.71
|
| Rate for Payer: Heritage Provider Network Senior |
$581.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$227.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$314.10
|
| Rate for Payer: Multiplan Commercial |
$942.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$453.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$415.99
|
|
