|
Transurethral resection of bladder neck (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 52500
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$131.84
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)
|
Facility
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64488
|
| Min. Negotiated Rate |
$2,869.00 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
|
|
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)
|
Facility
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64486
|
| Min. Negotiated Rate |
$2,869.00 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
OP
|
$1,870.10
|
|
|
Service Code
|
CPT J9355
|
| Hospital Charge Code |
ERX216113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.46 |
| Max. Negotiated Rate |
$1,402.58 |
| Rate for Payer: Adventist Health Commercial |
$374.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$158.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,284.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$100.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$88.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.93
|
| Rate for Payer: Blue Shield of California Commercial |
$105.97
|
| Rate for Payer: Blue Shield of California EPN |
$105.97
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$860.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.51
|
| Rate for Payer: Dignity Health Senior |
$88.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,196.86
|
| Rate for Payer: EPIC Health Plan Medicare |
$80.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$865.86
|
| Rate for Payer: Heritage Provider Network Senior |
$865.86
|
| Rate for Payer: Humana Medicare |
$80.46
|
| Rate for Payer: IEHP Medi-Cal |
$132.49
|
| Rate for Payer: IEHP Medicare Advantage |
$80.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$152.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$338.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$467.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$101.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$101.39
|
| Rate for Payer: Multiplan Commercial |
$1,402.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$88.51
|
| Rate for Payer: TriValley Medical Group Senior |
$80.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$681.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$624.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$120.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: Vantage Medical Group Senior |
$80.46
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
IP
|
$1,870.10
|
|
|
Service Code
|
CPT J9355
|
| Hospital Charge Code |
ERX216113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.49 |
| Max. Negotiated Rate |
$1,402.58 |
| Rate for Payer: Adventist Health Commercial |
$374.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,284.76
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$860.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,009.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,266.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1,266.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$338.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$467.52
|
| Rate for Payer: Multiplan Commercial |
$1,402.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$681.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$624.80
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
OP
|
$1,122.06
|
|
|
Service Code
|
CPT J9356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.02 |
| Max. Negotiated Rate |
$841.54 |
| Rate for Payer: Adventist Health Commercial |
$224.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$130.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$770.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$82.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$72.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$166.52
|
| Rate for Payer: Blue Shield of California Commercial |
$79.48
|
| Rate for Payer: Blue Shield of California EPN |
$79.48
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$516.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.62
|
| Rate for Payer: Dignity Health Senior |
$72.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$718.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$66.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$519.51
|
| Rate for Payer: Heritage Provider Network Senior |
$519.51
|
| Rate for Payer: Humana Medicare |
$66.02
|
| Rate for Payer: IEHP Medi-Cal |
$109.95
|
| Rate for Payer: IEHP Medicare Advantage |
$66.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$125.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$203.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$77.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$280.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$83.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$83.19
|
| Rate for Payer: Multiplan Commercial |
$841.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$72.62
|
| Rate for Payer: TriValley Medical Group Senior |
$66.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$409.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$374.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: Vantage Medical Group Senior |
$72.62
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
IP
|
$1,122.06
|
|
|
Service Code
|
CPT J9356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$203.09 |
| Max. Negotiated Rate |
$841.54 |
| Rate for Payer: Adventist Health Commercial |
$224.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$770.86
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$516.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$605.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$759.63
|
| Rate for Payer: Heritage Provider Network Senior |
$759.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$203.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$280.52
|
| Rate for Payer: Multiplan Commercial |
$841.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$409.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$374.88
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
IP
|
$1,632.08
|
|
|
Service Code
|
NDC 55513-141-01
|
| Hospital Charge Code |
ERX226189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$295.41 |
| Max. Negotiated Rate |
$1,224.06 |
| Rate for Payer: Adventist Health Commercial |
$326.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,121.24
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$750.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$881.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,104.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,104.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.02
|
| Rate for Payer: Multiplan Commercial |
$1,224.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$595.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$545.28
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
OP
|
$1,632.08
|
|
|
Service Code
|
NDC 55513-141-01
|
| Hospital Charge Code |
ERX226189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$295.41 |
| Max. Negotiated Rate |
$1,387.27 |
| Rate for Payer: Adventist Health Commercial |
$326.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$872.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,121.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,387.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$897.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,224.06
|
| Rate for Payer: Blue Shield of California Commercial |
$1,013.52
|
| Rate for Payer: Blue Shield of California EPN |
$958.03
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$750.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,387.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,387.27
|
| Rate for Payer: Dignity Health Senior |
$1,387.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,044.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$755.65
|
| Rate for Payer: Heritage Provider Network Senior |
$755.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$786.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.02
|
| Rate for Payer: Multiplan Commercial |
$1,224.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$595.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$545.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,387.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1,387.27
|
|
|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
IP
|
$4,569.82
|
|
|
Service Code
|
CPT Q5117
|
| Hospital Charge Code |
ERX225307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$827.14 |
| Max. Negotiated Rate |
$3,427.36 |
| Rate for Payer: Adventist Health Commercial |
$913.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,139.47
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,102.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,467.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,093.77
|
| Rate for Payer: Heritage Provider Network Senior |
$3,093.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$827.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,142.46
|
| Rate for Payer: Multiplan Commercial |
$3,427.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,666.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,526.78
|
|
|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
OP
|
$4,569.82
|
|
|
Service Code
|
CPT Q5117
|
| Hospital Charge Code |
ERX225307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$3,427.36 |
| Rate for Payer: Adventist Health Commercial |
$913.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,139.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$188.14
|
| Rate for Payer: Blue Shield of California Commercial |
$92.49
|
| Rate for Payer: Blue Shield of California EPN |
$92.49
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,102.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.40
|
| Rate for Payer: Dignity Health Senior |
$19.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,924.68
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,115.83
|
| Rate for Payer: Heritage Provider Network Senior |
$2,115.83
|
| Rate for Payer: Humana Medicare |
$17.64
|
| Rate for Payer: IEHP Medi-Cal |
$27.94
|
| Rate for Payer: IEHP Medicare Advantage |
$17.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$827.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,142.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.23
|
| Rate for Payer: Multiplan Commercial |
$3,427.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.40
|
| Rate for Payer: TriValley Medical Group Senior |
$17.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,666.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,526.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.40
|
| Rate for Payer: Vantage Medical Group Senior |
$19.40
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
OP
|
$60.37
|
|
|
Service Code
|
NDC 60505-0593-4
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$51.31 |
| Rate for Payer: Adventist Health Commercial |
$12.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.28
|
| Rate for Payer: Blue Shield of California Commercial |
$37.49
|
| Rate for Payer: Blue Shield of California EPN |
$35.44
|
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.31
|
| Rate for Payer: Dignity Health Senior |
$51.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.37
|
| Rate for Payer: Heritage Provider Network Senior |
$37.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$45.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.31
|
| Rate for Payer: Vantage Medical Group Senior |
$51.31
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
IP
|
$60.37
|
|
|
Service Code
|
NDC 60505-0593-4
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$45.28 |
| Rate for Payer: Adventist Health Commercial |
$12.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.47
|
| Rate for Payer: Cash Price |
$27.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.87
|
| Rate for Payer: Heritage Provider Network Senior |
$40.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$45.28
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
IP
|
$76.17
|
|
|
Service Code
|
NDC 0378-9651-32
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$57.13 |
| Rate for Payer: Adventist Health Commercial |
$15.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$52.33
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.57
|
| Rate for Payer: Heritage Provider Network Senior |
$51.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$57.13
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
OP
|
$76.17
|
|
|
Service Code
|
NDC 0378-9651-32
|
| Hospital Charge Code |
1740335
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$64.74 |
| Rate for Payer: Adventist Health Commercial |
$15.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$52.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$41.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$57.13
|
| Rate for Payer: Blue Shield of California Commercial |
$47.30
|
| Rate for Payer: Blue Shield of California EPN |
$44.71
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.74
|
| Rate for Payer: Dignity Health Senior |
$64.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.15
|
| Rate for Payer: Heritage Provider Network Senior |
$47.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$36.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.04
|
| Rate for Payer: Multiplan Commercial |
$57.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.74
|
| Rate for Payer: Vantage Medical Group Senior |
$64.74
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 50111-561-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-11
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
OP
|
$0.15
|
|
|
Service Code
|
NDC 68382-806-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Senior |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-11
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 50111-561-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 60687-454-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
IP
|
$0.15
|
|
|
Service Code
|
NDC 68382-806-01
|
| Hospital Charge Code |
1710080
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 68084-608-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
TRAZODONE 150 MG TABLET [8084]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 68382-807-01
|
| Hospital Charge Code |
ERX8084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
