|
TERLIPRESSIN 0.85 MG INTRAVENOUS POWDER FOR SOLUTION [235956]
|
Facility
|
OP
|
$1,256.40
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.41 |
| Max. Negotiated Rate |
$1,067.94 |
| Rate for Payer: Adventist Health Commercial |
$251.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$776.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$691.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$942.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$628.45
|
| Rate for Payer: Blue Shield of California Commercial |
$766.40
|
| Rate for Payer: Blue Shield of California EPN |
$613.12
|
| Rate for Payer: Cash Price |
$565.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$577.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,067.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,067.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$804.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$581.71
|
| Rate for Payer: Heritage Provider Network Senior |
$581.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$599.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$227.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$314.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$879.48
|
| Rate for Payer: Multiplan Commercial |
$942.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$502.56
|
| Rate for Payer: TriValley Medical Group Senior |
$502.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$453.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$415.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,067.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,067.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1,067.94
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$32,699.32
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$24,402.48 |
| Max. Negotiated Rate |
$32,699.32 |
| Rate for Payer: EPIC Health Plan Medicare |
$24,402.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,402.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,062.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32,699.32
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$17,588.00
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$13,125.37 |
| Max. Negotiated Rate |
$17,588.00 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,125.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,125.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,094.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,588.00
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$8.92 |
| Rate for Payer: Adventist Health Commercial |
$2.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.48
|
| 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 |
$0.16
|
| 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 |
$4.72
|
| Rate for Payer: Cash Price |
$4.72
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$5.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 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: Aetna of CA Non-Gatekeeper |
$6.76
|
| Rate for Payer: Cash Price |
$4.72
|
| 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 Foundation Hospitals 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 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 |
$0.04 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Adventist Health Commercial |
$4.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.75
|
| 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 |
$0.16
|
| 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 |
$10.01
|
| Rate for Payer: Cash Price |
$10.01
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$10.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
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: Aetna of CA Non-Gatekeeper |
$14.33
|
| Rate for Payer: Cash Price |
$10.01
|
| 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 Foundation Hospitals 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
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
OP
|
$106.59
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$90.60 |
| Rate for Payer: Adventist Health Commercial |
$21.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$49.36
|
| 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 |
$47.97
|
| Rate for Payer: Cash Price |
$47.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.35
|
| Rate for Payer: Heritage Provider Network Senior |
$49.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$50.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$74.61
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.64
|
| Rate for Payer: TriValley Medical Group Senior |
$42.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.60
|
| Rate for Payer: Vantage Medical Group Senior |
$90.60
|
|
|
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE [119618]
|
Facility
|
IP
|
$106.59
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$79.94 |
| Rate for Payer: Adventist Health Commercial |
$21.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.64
|
| Rate for Payer: Cash Price |
$47.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.35
|
| Rate for Payer: Heritage Provider Network Senior |
$49.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.65
|
| Rate for Payer: Multiplan Commercial |
$79.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$38.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.29
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
IP
|
$786.79
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.41 |
| Max. Negotiated Rate |
$590.09 |
| Rate for Payer: Adventist Health Commercial |
$157.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$506.69
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$361.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$424.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.28
|
| Rate for Payer: Heritage Provider Network Senior |
$364.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$196.70
|
| Rate for Payer: Multiplan Commercial |
$590.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.51
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
|
OP
|
$786.79
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.41 |
| Max. Negotiated Rate |
$797.33 |
| Rate for Payer: Adventist Health Commercial |
$157.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$743.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$654.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$654.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$242.44
|
| Rate for Payer: Blue Shield of California Commercial |
$662.15
|
| Rate for Payer: Blue Shield of California EPN |
$662.15
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Cash Price |
$354.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$361.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$743.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$654.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$654.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$503.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$595.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.28
|
| Rate for Payer: Heritage Provider Network Senior |
$364.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$595.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$375.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$684.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$196.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$797.33
|
| Rate for Payer: Multiplan Commercial |
$590.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$314.72
|
| Rate for Payer: TriValley Medical Group Senior |
$314.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$284.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$260.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$743.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$654.52
|
| Rate for Payer: Vantage Medical Group Senior |
$654.52
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| 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 Non-Gatekeeper |
$0.99
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| 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 |
$0.72
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| 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: Aetna of CA Non-Gatekeeper |
$10.11
|
| Rate for Payer: Cash Price |
$7.06
|
| 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 Foundation Hospitals 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
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Senior |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.01
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 4359839467
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Senior |
$1.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$2.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.28
|
| Rate for Payer: Vantage Medical Group Senior |
$2.28
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 4733527723
|
| 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 Non-Gatekeeper |
$9.70
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$7.85
|
| 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 |
$7.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$7.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$1.61
|
|
|
Service Code
|
NDC 6945211721
|
| 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: Aetna of CA Non-Gatekeeper |
$1.04
|
| Rate for Payer: Cash Price |
$0.72
|
| 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 Foundation Hospitals 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 6738642201
|
| 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: Aetna of CA Non-Gatekeeper |
$293.51
|
| Rate for Payer: Cash Price |
$205.09
|
| 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 Foundation Hospitals 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 6738642201
|
| 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 Non-Gatekeeper |
$281.66
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$227.97
|
| 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 |
$205.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$217.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$82.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$113.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
OP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| 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 Non-Gatekeeper |
$2.57
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$2.08
|
| 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 |
$1.87
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
|
IP
|
$4.16
|
|
|
Service Code
|
NDC 0065074114
|
| 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: Aetna of CA Non-Gatekeeper |
$2.68
|
| Rate for Payer: Cash Price |
$1.87
|
| 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 Foundation Hospitals Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.12
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
NDC 6213526660
|
| 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 Non-Gatekeeper |
$2.43
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.97
|
| 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 |
$1.77
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| 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 Non-Gatekeeper |
$1.26
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| 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 |
$0.92
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 5199190701
|
| 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: Aetna of CA Non-Gatekeeper |
$1.31
|
| Rate for Payer: Cash Price |
$0.92
|
| 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 Foundation Hospitals 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
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 2315576701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.73
|
| Rate for Payer: Adventist Health Commercial |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.26
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| 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 |
$0.92
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$1.73
|
|
