|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
IP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.16 |
| Max. Negotiated Rate |
$50.37 |
| Rate for Payer: Adventist Health Commercial |
$13.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.14
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.47
|
| Rate for Payer: Heritage Provider Network Senior |
$45.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.79
|
| Rate for Payer: Multiplan Commercial |
$50.37
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [37504]
|
Facility
OP
|
$67.16
|
|
|
Service Code
|
CPT 90718
|
| Hospital Charge Code |
NDG37504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.16 |
| Max. Negotiated Rate |
$57.09 |
| Rate for Payer: Adventist Health Commercial |
$13.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$57.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$50.37
|
| Rate for Payer: Blue Shield of California Commercial |
$41.71
|
| Rate for Payer: Blue Shield of California EPN |
$39.42
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.09
|
| Rate for Payer: Dignity Health Senior |
$57.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.57
|
| Rate for Payer: Heritage Provider Network Senior |
$41.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.79
|
| Rate for Payer: Multiplan Commercial |
$50.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.09
|
| Rate for Payer: Vantage Medical Group Senior |
$57.09
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
OP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.89 |
| Max. Negotiated Rate |
$1,421.44 |
| Rate for Payer: Adventist Health Commercial |
$151.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,421.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$519.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$723.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$636.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$213.73
|
| Rate for Payer: Blue Shield of California Commercial |
$624.14
|
| Rate for Payer: Blue Shield of California EPN |
$624.14
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$347.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$867.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$636.47
|
| Rate for Payer: Dignity Health Senior |
$636.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$484.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$578.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$350.17
|
| Rate for Payer: Heritage Provider Network Senior |
$350.17
|
| Rate for Payer: Humana Medicare |
$578.61
|
| Rate for Payer: IEHP Medi-Cal |
$909.59
|
| Rate for Payer: IEHP Medicare Advantage |
$578.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,099.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$682.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$729.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$729.05
|
| Rate for Payer: Multiplan Commercial |
$567.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$636.47
|
| Rate for Payer: TriValley Medical Group Senior |
$578.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$867.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$636.47
|
| Rate for Payer: Vantage Medical Group Senior |
$578.61
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [119764]
|
Facility
IP
|
$756.31
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
1720797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.89 |
| Max. Negotiated Rate |
$567.23 |
| Rate for Payer: Adventist Health Commercial |
$151.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$519.58
|
| Rate for Payer: Cash Price |
$340.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$347.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$408.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$512.02
|
| Rate for Payer: Heritage Provider Network Senior |
$512.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.08
|
| Rate for Payer: Multiplan Commercial |
$567.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.68
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
IP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
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 |
$10.79
|
| Rate for Payer: Cash Price |
$7.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.63
|
| Rate for Payer: Heritage Provider Network Senior |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
OP
|
$15.70
|
|
|
Service Code
|
NDC 47335-277-23
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$13.34 |
| Rate for Payer: Adventist Health Commercial |
$3.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.78
|
| Rate for Payer: Blue Shield of California Commercial |
$9.75
|
| Rate for Payer: Blue Shield of California EPN |
$9.22
|
| Rate for Payer: Cash Price |
$7.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.34
|
| Rate for Payer: Dignity Health Senior |
$13.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.72
|
| Rate for Payer: Heritage Provider Network Senior |
$9.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.34
|
| Rate for Payer: Vantage Medical Group Senior |
$13.34
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
IP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.47
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.38
|
| Rate for Payer: Heritage Provider Network Senior |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
|
|
TETRABENAZINE 12.5 MG TABLET [94563]
|
Facility
OP
|
$9.42
|
|
|
Service Code
|
NDC 43598-394-67
|
| Hospital Charge Code |
1712628
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Adventist Health Commercial |
$1.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.06
|
| Rate for Payer: Blue Shield of California Commercial |
$5.85
|
| Rate for Payer: Blue Shield of California EPN |
$5.53
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.01
|
| Rate for Payer: Dignity Health Senior |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.83
|
| Rate for Payer: Heritage Provider Network Senior |
$5.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: Multiplan Commercial |
$7.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$8.01
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
OP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$71.95 |
| Max. Negotiated Rate |
$337.87 |
| Rate for Payer: Adventist Health Commercial |
$79.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$273.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$337.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$218.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$298.12
|
| Rate for Payer: Blue Shield of California Commercial |
$246.84
|
| Rate for Payer: Blue Shield of California EPN |
$233.33
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$258.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$337.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$337.87
|
| Rate for Payer: Dignity Health Senior |
$337.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$254.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.05
|
| Rate for Payer: Heritage Provider Network Senior |
$246.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$191.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.37
|
| Rate for Payer: Multiplan Commercial |
$298.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$337.87
|
| Rate for Payer: Vantage Medical Group Senior |
$337.87
|
|
|
TETRABENAZINE 25 MG TABLET [92777]
|
Facility
IP
|
$397.49
|
|
|
Service Code
|
NDC 67386-422-01
|
| Hospital Charge Code |
1712629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$71.95 |
| Max. Negotiated Rate |
$298.12 |
| Rate for Payer: Adventist Health Commercial |
$79.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$273.08
|
| Rate for Payer: Cash Price |
$178.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.10
|
| Rate for Payer: Heritage Provider Network Senior |
$269.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.37
|
| Rate for Payer: Multiplan Commercial |
$298.12
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
IP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.87
|
| Rate for Payer: Heritage Provider Network Senior |
$4.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
|
|
TETRACAINE 0.5 % EYE DROPS [7795]
|
Facility
OP
|
$7.20
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
NDG7795
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Adventist Health Commercial |
$1.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.40
|
| Rate for Payer: Blue Shield of California Commercial |
$4.47
|
| Rate for Payer: Blue Shield of California EPN |
$4.23
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.12
|
| Rate for Payer: Dignity Health Senior |
$6.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.46
|
| Rate for Payer: Heritage Provider Network Senior |
$4.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$5.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.12
|
| Rate for Payer: Vantage Medical Group Senior |
$6.12
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
OP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.18
|
| Rate for Payer: Dignity Health Senior |
$3.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.32
|
| Rate for Payer: Heritage Provider Network Senior |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3.18
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [121651]
|
Facility
IP
|
$3.74
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
NDG121651B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.57
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Senior |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
IP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$34.18 |
| Rate for Payer: Adventist Health Commercial |
$9.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.31
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.85
|
| Rate for Payer: Heritage Provider Network Senior |
$30.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.39
|
| Rate for Payer: Multiplan Commercial |
$34.18
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [11517]
|
Facility
OP
|
$45.57
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
1720080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$38.73 |
| Rate for Payer: Adventist Health Commercial |
$9.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.18
|
| Rate for Payer: Blue Shield of California Commercial |
$28.30
|
| Rate for Payer: Blue Shield of California EPN |
$26.75
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.73
|
| Rate for Payer: Dignity Health Senior |
$38.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.21
|
| Rate for Payer: Heritage Provider Network Senior |
$28.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.39
|
| Rate for Payer: Multiplan Commercial |
$34.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.73
|
| Rate for Payer: Vantage Medical Group Senior |
$38.73
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 51991-907-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.31
|
| 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 Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
IP
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
|
|
TETRACYCLINE 500 MG CAPSULE [7797]
|
Facility
OP
|
$3.94
|
|
|
Service Code
|
NDC 62135-266-60
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.31
|
| 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 Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| 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
|
$3.94
|
|
|
Service Code
|
NDC 23155-767-01
|
| Hospital Charge Code |
1710677
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.45
|
| Rate for Payer: Blue Shield of California EPN |
$2.31
|
| 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 Senior |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$2.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.35
|
| Rate for Payer: Vantage Medical Group Senior |
$3.35
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
TETRACYCLINE ORAL SUSPENSION COMPOUND 25 MG/ML [4080348]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 9994-0803-48
|
| Hospital Charge Code |
1715971
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) INTRAVENOUS SOLUTION [98468]
|
Facility
IP
|
$94.83
|
|
|
Service Code
|
CPT A9505
|
| Hospital Charge Code |
ERX98468
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$71.12 |
| Rate for Payer: Adventist Health Commercial |
$18.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.15
|
| Rate for Payer: Cash Price |
$42.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.20
|
| Rate for Payer: Heritage Provider Network Senior |
$64.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.71
|
| Rate for Payer: Multiplan Commercial |
$71.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.68
|
|
