|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 68382-132-01
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 62756-160-88
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904-6401-89
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
OP
|
$0.71
|
|
|
Service Code
|
NDC 68084-299-11
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 62756-160-88
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 0904-6401-89
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| 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 |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 68084-299-01
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
OP
|
$0.71
|
|
|
Service Code
|
NDC 68084-299-01
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [103890]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 68382-132-01
|
| Hospital Charge Code |
1711755
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
TAPENTADOL 50 MG TABLET [98253]
|
Facility
IP
|
$11.56
|
|
|
Service Code
|
NDC 24510-050-10
|
| Hospital Charge Code |
1730175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Adventist Health Commercial |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.94
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.83
|
| Rate for Payer: Heritage Provider Network Senior |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$8.67
|
|
|
TAPENTADOL 50 MG TABLET [98253]
|
Facility
OP
|
$11.56
|
|
|
Service Code
|
NDC 24510-050-10
|
| Hospital Charge Code |
1730175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$9.83 |
| Rate for Payer: Adventist Health Commercial |
$2.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.67
|
| Rate for Payer: Blue Shield of California Commercial |
$7.18
|
| Rate for Payer: Blue Shield of California EPN |
$6.79
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.83
|
| Rate for Payer: Dignity Health Senior |
$9.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.16
|
| Rate for Payer: Heritage Provider Network Senior |
$7.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$8.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.83
|
| Rate for Payer: Vantage Medical Group Senior |
$9.83
|
|
|
Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11920
|
| Min. Negotiated Rate |
$784.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
OP
|
$88.73
|
|
|
Service Code
|
NDC 72607-100-00
|
| Hospital Charge Code |
ERX226994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$75.42 |
| Rate for Payer: Adventist Health Commercial |
$17.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$75.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$48.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.55
|
| Rate for Payer: Blue Shield of California Commercial |
$55.10
|
| Rate for Payer: Blue Shield of California EPN |
$52.08
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$57.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$75.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$75.42
|
| Rate for Payer: Dignity Health Senior |
$75.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.92
|
| Rate for Payer: Heritage Provider Network Senior |
$54.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.18
|
| Rate for Payer: Multiplan Commercial |
$66.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$75.42
|
| Rate for Payer: Vantage Medical Group Senior |
$75.42
|
|
|
TAZEMETOSTAT 200 MG TABLET [226994]
|
Facility
IP
|
$88.73
|
|
|
Service Code
|
NDC 72607-100-00
|
| Hospital Charge Code |
ERX226994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$66.55 |
| Rate for Payer: Adventist Health Commercial |
$17.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.96
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.07
|
| Rate for Payer: Heritage Provider Network Senior |
$60.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.18
|
| Rate for Payer: Multiplan Commercial |
$66.55
|
|
|
TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION [233477]
|
Facility
IP
|
$47,304.00
|
|
|
Service Code
|
CPT J9274
|
| Hospital Charge Code |
NDG233477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,562.02 |
| Max. Negotiated Rate |
$35,478.00 |
| Rate for Payer: Adventist Health Commercial |
$9,460.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32,497.85
|
| Rate for Payer: Cash Price |
$21,286.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21,759.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$25,544.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$32,024.81
|
| Rate for Payer: Heritage Provider Network Senior |
$32,024.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,562.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,826.00
|
| Rate for Payer: Multiplan Commercial |
$35,478.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17,247.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15,804.27
|
|
|
TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION [233477]
|
Facility
OP
|
$47,304.00
|
|
|
Service Code
|
CPT J9274
|
| Hospital Charge Code |
NDG233477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.35 |
| Max. Negotiated Rate |
$35,478.00 |
| Rate for Payer: Adventist Health Commercial |
$9,460.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$513.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32,497.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$261.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$229.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$229.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$400.87
|
| Rate for Payer: Blue Shield of California Commercial |
$191.35
|
| Rate for Payer: Blue Shield of California EPN |
$191.35
|
| Rate for Payer: Cash Price |
$21,286.80
|
| Rate for Payer: Cash Price |
$21,286.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21,759.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$261.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$229.82
|
| Rate for Payer: Dignity Health Senior |
$229.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,274.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$208.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$21,901.75
|
| Rate for Payer: Heritage Provider Network Senior |
$21,901.75
|
| Rate for Payer: Humana Medicare |
$208.93
|
| Rate for Payer: IEHP Medi-Cal |
$332.89
|
| Rate for Payer: IEHP Medicare Advantage |
$208.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$396.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,562.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$246.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,826.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$263.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$263.25
|
| Rate for Payer: Multiplan Commercial |
$35,478.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$229.82
|
| Rate for Payer: TriValley Medical Group Senior |
$208.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17,247.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15,804.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$261.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$229.82
|
| Rate for Payer: Vantage Medical Group Senior |
$229.82
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
IP
|
$708.00
|
|
|
Service Code
|
CPT J9380
|
| Hospital Charge Code |
NDG236039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.15 |
| Max. Negotiated Rate |
$531.00 |
| Rate for Payer: Adventist Health Commercial |
$141.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.40
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$325.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$382.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$479.32
|
| Rate for Payer: Heritage Provider Network Senior |
$479.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.00
|
| Rate for Payer: Multiplan Commercial |
$531.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$258.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$236.54
|
|
|
TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION [236039]
|
Facility
OP
|
$708.00
|
|
|
Service Code
|
CPT J9380
|
| Hospital Charge Code |
NDG236039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$531.00 |
| Rate for Payer: Adventist Health Commercial |
$141.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$486.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.93
|
| Rate for Payer: Blue Shield of California Commercial |
$439.67
|
| Rate for Payer: Blue Shield of California EPN |
$415.60
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cash Price |
$318.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$325.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.93
|
| Rate for Payer: Dignity Health Senior |
$33.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$453.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$327.80
|
| Rate for Payer: Heritage Provider Network Senior |
$327.80
|
| Rate for Payer: Humana Medicare |
$30.85
|
| Rate for Payer: IEHP Medi-Cal |
$55.08
|
| Rate for Payer: IEHP Medicare Advantage |
$30.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$177.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$38.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$38.87
|
| Rate for Payer: Multiplan Commercial |
$531.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.93
|
| Rate for Payer: TriValley Medical Group Senior |
$30.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$258.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$236.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.93
|
| Rate for Payer: Vantage Medical Group Senior |
$33.93
|
|
|
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION [236038]
|
Facility
IP
|
$6,372.00
|
|
|
Service Code
|
CPT J9380
|
| Hospital Charge Code |
NDG236038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,153.33 |
| Max. Negotiated Rate |
$4,779.00 |
| Rate for Payer: Adventist Health Commercial |
$1,274.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,377.56
|
| Rate for Payer: Cash Price |
$2,867.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,931.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,440.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,313.84
|
| Rate for Payer: Heritage Provider Network Senior |
$4,313.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,153.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,593.00
|
| Rate for Payer: Multiplan Commercial |
$4,779.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,323.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,128.89
|
|
|
TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION [236038]
|
Facility
OP
|
$6,372.00
|
|
|
Service Code
|
CPT J9380
|
| Hospital Charge Code |
NDG236038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$4,779.00 |
| Rate for Payer: Adventist Health Commercial |
$1,274.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,377.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3,957.01
|
| Rate for Payer: Blue Shield of California EPN |
$3,740.36
|
| Rate for Payer: Cash Price |
$2,867.40
|
| Rate for Payer: Cash Price |
$2,867.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,931.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.93
|
| Rate for Payer: Dignity Health Senior |
$33.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,078.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,950.24
|
| Rate for Payer: Heritage Provider Network Senior |
$2,950.24
|
| Rate for Payer: Humana Medicare |
$30.85
|
| Rate for Payer: IEHP Medi-Cal |
$55.08
|
| Rate for Payer: IEHP Medicare Advantage |
$30.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,153.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,593.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$38.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$38.87
|
| Rate for Payer: Multiplan Commercial |
$4,779.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.93
|
| Rate for Payer: TriValley Medical Group Senior |
$30.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,323.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,128.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.93
|
| Rate for Payer: Vantage Medical Group Senior |
$33.93
|
|
|
TEDIZOLID 200 MG INTRAVENOUS SOLUTION [206225]
|
Facility
IP
|
$369.29
|
|
|
Service Code
|
CPT J3090
|
| Hospital Charge Code |
ERX206225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.84 |
| Max. Negotiated Rate |
$276.97 |
| Rate for Payer: Adventist Health Commercial |
$73.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$253.70
|
| Rate for Payer: Cash Price |
$166.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.01
|
| Rate for Payer: Heritage Provider Network Senior |
$250.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.32
|
| Rate for Payer: Multiplan Commercial |
$276.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$123.38
|
|
|
TEDIZOLID 200 MG INTRAVENOUS SOLUTION [206225]
|
Facility
OP
|
$369.29
|
|
|
Service Code
|
CPT J3090
|
| Hospital Charge Code |
ERX206225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$276.97 |
| Rate for Payer: Adventist Health Commercial |
$73.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$253.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.72
|
| Rate for Payer: Cash Price |
$166.18
|
| Rate for Payer: Cash Price |
$166.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$169.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.96
|
| Rate for Payer: Dignity Health Senior |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$236.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$170.98
|
| Rate for Payer: Heritage Provider Network Senior |
$170.98
|
| Rate for Payer: Humana Medicare |
$1.78
|
| Rate for Payer: IEHP Medi-Cal |
$9.73
|
| Rate for Payer: IEHP Medicare Advantage |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$276.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.96
|
| Rate for Payer: TriValley Medical Group Senior |
$1.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$134.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$123.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: Vantage Medical Group Senior |
$1.78
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
OP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
1710970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.21
|
| Rate for Payer: Blue Shield of California Commercial |
$3.48
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.77
|
| Rate for Payer: Dignity Health Senior |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.77
|
| Rate for Payer: Vantage Medical Group Senior |
$4.77
|
|
|
TELMISARTAN 40 MG TABLET [24335]
|
Facility
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0040-37
|
| Hospital Charge Code |
1710970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
|
|
TELMISARTAN 80 MG TABLET [24336]
|
Facility
IP
|
$5.61
|
|
|
Service Code
|
NDC 0597-0041-37
|
| Hospital Charge Code |
1710961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Adventist Health Commercial |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.85
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.80
|
| Rate for Payer: Heritage Provider Network Senior |
$3.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$4.21
|
|
