|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: Blue Distinction Transplant |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Media |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
IP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Blue Shield of California Commercial |
$130.72
|
| Rate for Payer: Blue Shield of California EPN |
$94.00
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO |
$128.52
|
| Rate for Payer: Cigna of CA PPO |
$128.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.06
|
| Rate for Payer: Multiplan Commercial |
$146.88
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$69.33
|
| Rate for Payer: United Healthcare All Other HMO |
$67.71
|
| Rate for Payer: United Healthcare HMO Rider |
$66.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.59
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
OP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$389.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$100.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Blue Distinction Transplant |
$110.16
|
| Rate for Payer: Blue Shield of California Commercial |
$135.31
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO |
$128.52
|
| Rate for Payer: Cigna of CA PPO |
$128.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$156.06
|
| Rate for Payer: Dignity Health Media |
$156.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$137.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.06
|
| Rate for Payer: Multiplan Commercial |
$146.88
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.80
|
| Rate for Payer: United Healthcare All Other HMO |
$91.80
|
| Rate for Payer: United Healthcare HMO Rider |
$91.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$91.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$156.06
|
| Rate for Payer: Vantage Medical Group Senior |
$156.06
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
|
OP
|
$163.52
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$389.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$89.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Blue Distinction Transplant |
$15.84
|
| Rate for Payer: Blue Distinction Transplant |
$70.56
|
| Rate for Payer: Blue Distinction Transplant |
$98.11
|
| Rate for Payer: Blue Shield of California Commercial |
$120.51
|
| Rate for Payer: Blue Shield of California Commercial |
$86.67
|
| Rate for Payer: Blue Shield of California Commercial |
$19.46
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cigna of CA HMO |
$18.48
|
| Rate for Payer: Cigna of CA HMO |
$114.46
|
| Rate for Payer: Cigna of CA HMO |
$82.32
|
| Rate for Payer: Cigna of CA PPO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$114.46
|
| Rate for Payer: Cigna of CA PPO |
$82.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$138.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.96
|
| Rate for Payer: Dignity Health Media |
$99.96
|
| Rate for Payer: Dignity Health Media |
$138.99
|
| Rate for Payer: Dignity Health Media |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$138.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$65.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$47.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.56
|
| Rate for Payer: Galaxy Health WC |
$22.44
|
| Rate for Payer: Galaxy Health WC |
$138.99
|
| Rate for Payer: Galaxy Health WC |
$99.96
|
| Rate for Payer: Global Benefits Group Commercial |
$15.84
|
| Rate for Payer: Global Benefits Group Commercial |
$98.11
|
| Rate for Payer: Global Benefits Group Commercial |
$70.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$122.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$88.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$109.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.22
|
| Rate for Payer: Multiplan Commercial |
$21.12
|
| Rate for Payer: Multiplan Commercial |
$94.08
|
| Rate for Payer: Multiplan Commercial |
$130.82
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Networks By Design Commercial |
$81.76
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: Prime Health Services Commercial |
$138.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$98.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$98.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$81.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.80
|
| Rate for Payer: United Healthcare All Other HMO |
$13.20
|
| Rate for Payer: United Healthcare All Other HMO |
$81.76
|
| Rate for Payer: United Healthcare All Other HMO |
$58.80
|
| Rate for Payer: United Healthcare HMO Rider |
$58.80
|
| Rate for Payer: United Healthcare HMO Rider |
$13.20
|
| Rate for Payer: United Healthcare HMO Rider |
$81.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$138.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$22.44
|
| Rate for Payer: Vantage Medical Group Senior |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$138.99
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
|
IP
|
$117.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.22 |
| Max. Negotiated Rate |
$99.96 |
| Rate for Payer: Blue Shield of California Commercial |
$83.73
|
| Rate for Payer: Blue Shield of California Commercial |
$116.43
|
| Rate for Payer: Blue Shield of California Commercial |
$18.80
|
| Rate for Payer: Blue Shield of California EPN |
$83.72
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Blue Shield of California EPN |
$60.21
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cigna of CA HMO |
$18.48
|
| Rate for Payer: Cigna of CA HMO |
$114.46
|
| Rate for Payer: Cigna of CA HMO |
$82.32
|
| Rate for Payer: Cigna of CA PPO |
$82.32
|
| Rate for Payer: Cigna of CA PPO |
$114.46
|
| Rate for Payer: Cigna of CA PPO |
$18.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$47.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$65.41
|
| Rate for Payer: Galaxy Health WC |
$138.99
|
| Rate for Payer: Galaxy Health WC |
$99.96
|
| Rate for Payer: Galaxy Health WC |
$22.44
|
| Rate for Payer: Global Benefits Group Commercial |
$15.84
|
| Rate for Payer: Global Benefits Group Commercial |
$70.56
|
| Rate for Payer: Global Benefits Group Commercial |
$98.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$109.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$94.08
|
| Rate for Payer: Multiplan Commercial |
$130.82
|
| Rate for Payer: Multiplan Commercial |
$21.12
|
| Rate for Payer: Networks By Design Commercial |
$81.76
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: Prime Health Services Commercial |
$138.99
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$61.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.41
|
| Rate for Payer: United Healthcare All Other HMO |
$60.31
|
| Rate for Payer: United Healthcare All Other HMO |
$43.37
|
| Rate for Payer: United Healthcare All Other HMO |
$9.74
|
| Rate for Payer: United Healthcare HMO Rider |
$9.53
|
| Rate for Payer: United Healthcare HMO Rider |
$42.43
|
| Rate for Payer: United Healthcare HMO Rider |
$59.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.71
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Distinction Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
|
IP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: Blue Shield of California Commercial |
$191.27
|
| Rate for Payer: Blue Shield of California EPN |
$137.54
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO |
$188.05
|
| Rate for Payer: Cigna of CA PPO |
$188.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.46
|
| Rate for Payer: Galaxy Health WC |
$228.34
|
| Rate for Payer: Global Benefits Group Commercial |
$161.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.47
|
| Rate for Payer: Multiplan Commercial |
$214.91
|
| Rate for Payer: Networks By Design Commercial |
$174.62
|
| Rate for Payer: Prime Health Services Commercial |
$228.34
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
|
OP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$176.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$147.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.06
|
| Rate for Payer: Blue Distinction Transplant |
$161.18
|
| Rate for Payer: Blue Shield of California Commercial |
$197.99
|
| Rate for Payer: Blue Shield of California EPN |
$156.89
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO |
$188.05
|
| Rate for Payer: Cigna of CA PPO |
$188.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.34
|
| Rate for Payer: Dignity Health Media |
$228.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$107.46
|
| Rate for Payer: Galaxy Health WC |
$228.34
|
| Rate for Payer: Global Benefits Group Commercial |
$161.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$201.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.47
|
| Rate for Payer: Multiplan Commercial |
$214.91
|
| Rate for Payer: Networks By Design Commercial |
$174.62
|
| Rate for Payer: Prime Health Services Commercial |
$228.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.32
|
| Rate for Payer: United Healthcare All Other HMO |
$134.32
|
| Rate for Payer: United Healthcare HMO Rider |
$134.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.34
|
| Rate for Payer: Vantage Medical Group Senior |
$228.34
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
|
OP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$128.95 |
| Max. Negotiated Rate |
$456.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$352.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$456.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$295.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$295.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$320.12
|
| Rate for Payer: Blue Distinction Transplant |
$322.37
|
| Rate for Payer: Blue Shield of California Commercial |
$395.98
|
| Rate for Payer: Blue Shield of California EPN |
$313.78
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: Cigna of CA HMO |
$376.10
|
| Rate for Payer: Cigna of CA PPO |
$376.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$456.70
|
| Rate for Payer: Dignity Health Media |
$456.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$456.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.92
|
| Rate for Payer: Galaxy Health WC |
$456.70
|
| Rate for Payer: Global Benefits Group Commercial |
$322.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$402.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.95
|
| Rate for Payer: Multiplan Commercial |
$429.83
|
| Rate for Payer: Networks By Design Commercial |
$349.24
|
| Rate for Payer: Prime Health Services Commercial |
$456.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$322.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$322.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$268.64
|
| Rate for Payer: United Healthcare All Other HMO |
$268.64
|
| Rate for Payer: United Healthcare HMO Rider |
$268.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$268.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$456.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$456.70
|
| Rate for Payer: Vantage Medical Group Senior |
$456.70
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
|
IP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$128.95 |
| Max. Negotiated Rate |
$456.70 |
| Rate for Payer: Blue Shield of California Commercial |
$382.55
|
| Rate for Payer: Blue Shield of California EPN |
$275.09
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: Cigna of CA HMO |
$376.10
|
| Rate for Payer: Cigna of CA PPO |
$376.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.92
|
| Rate for Payer: Galaxy Health WC |
$456.70
|
| Rate for Payer: Global Benefits Group Commercial |
$322.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.95
|
| Rate for Payer: Multiplan Commercial |
$429.83
|
| Rate for Payer: Networks By Design Commercial |
$349.24
|
| Rate for Payer: Prime Health Services Commercial |
$456.70
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
IP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$224.48 |
| Max. Negotiated Rate |
$795.05 |
| Rate for Payer: Blue Shield of California Commercial |
$665.97
|
| Rate for Payer: Blue Shield of California EPN |
$478.90
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: Cigna of CA HMO |
$654.74
|
| Rate for Payer: Cigna of CA PPO |
$654.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$374.14
|
| Rate for Payer: Galaxy Health WC |
$795.05
|
| Rate for Payer: Global Benefits Group Commercial |
$561.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$623.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$356.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$748.28
|
| Rate for Payer: Networks By Design Commercial |
$607.98
|
| Rate for Payer: Prime Health Services Commercial |
$795.05
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
OP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$224.48 |
| Max. Negotiated Rate |
$795.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$613.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$795.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$514.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$514.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$557.28
|
| Rate for Payer: Blue Distinction Transplant |
$561.21
|
| Rate for Payer: Blue Shield of California Commercial |
$689.35
|
| Rate for Payer: Blue Shield of California EPN |
$546.24
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: Cigna of CA HMO |
$654.74
|
| Rate for Payer: Cigna of CA PPO |
$654.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$795.05
|
| Rate for Payer: Dignity Health Media |
$795.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$795.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$374.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$374.14
|
| Rate for Payer: Galaxy Health WC |
$795.05
|
| Rate for Payer: Global Benefits Group Commercial |
$561.21
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$701.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$623.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$356.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$748.28
|
| Rate for Payer: Networks By Design Commercial |
$607.98
|
| Rate for Payer: Prime Health Services Commercial |
$795.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$561.21
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$561.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$467.68
|
| Rate for Payer: United Healthcare All Other HMO |
$467.68
|
| Rate for Payer: United Healthcare HMO Rider |
$467.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$467.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$795.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$795.05
|
| Rate for Payer: Vantage Medical Group Senior |
$795.05
|
|
|
Surgical closure tracheostomy or fistula; without plastic repair
|
Facility
|
OP
|
$6,597.21
|
|
|
Service Code
|
CPT 31820
|
| Min. Negotiated Rate |
$394.00 |
| Max. Negotiated Rate |
$6,597.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Media |
$4,022.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,597.21
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,597.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6,516.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$394.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 281020545
|
| Hospital Charge Code |
NDG112826C
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 281020545
|
| Hospital Charge Code |
NDG112826C
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)
|
Facility
|
OP
|
$23,735.78
|
|
|
Service Code
|
CPT S2900
|
| Min. Negotiated Rate |
$23,735.78 |
| Max. Negotiated Rate |
$23,735.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,735.78
|
|
|
Suture of digital nerve, hand or foot; 1 nerve
|
Facility
|
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 64831
|
| Min. Negotiated Rate |
$107.52 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,412.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Dignity Health Media |
$2,412.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,653.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,256.71
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,412.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,412.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,956.30
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,956.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,908.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,908.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,412.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,412.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,039.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,232.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2,412.38
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$20,557.94
|
|
|
Service Code
|
APR-DRG 2044
|
| Min. Negotiated Rate |
$15,770.11 |
| Max. Negotiated Rate |
$20,557.94 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,770.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,557.94
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$13,120.05
|
|
|
Service Code
|
APR-DRG 2043
|
| Min. Negotiated Rate |
$10,064.46 |
| Max. Negotiated Rate |
$13,120.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,064.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,120.05
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$10,183.20
|
|
|
Service Code
|
APR-DRG 2042
|
| Min. Negotiated Rate |
$7,811.59 |
| Max. Negotiated Rate |
$10,183.20 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,811.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,183.20
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$8,661.59
|
|
|
Service Code
|
APR-DRG 2041
|
| Min. Negotiated Rate |
$6,644.35 |
| Max. Negotiated Rate |
$8,661.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,644.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,661.59
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 45802-390-00
|
| Hospital Charge Code |
1743765
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.67
|
| Rate for Payer: Blue Distinction Transplant |
$1.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.64
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$1.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.38
|
| Rate for Payer: Dignity Health Media |
$2.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.38
|
| Rate for Payer: Global Benefits Group Commercial |
$1.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
| Rate for Payer: Networks By Design Commercial |
$1.82
|
| Rate for Payer: Prime Health Services Commercial |
$2.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Vantage Medical Group Senior |
$2.38
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 45802-390-00
|
| Hospital Charge Code |
1743765
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Blue Shield of California Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.38
|
| Rate for Payer: Global Benefits Group Commercial |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
| Rate for Payer: Networks By Design Commercial |
$1.82
|
| Rate for Payer: Prime Health Services Commercial |
$2.38
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 45802-700-01
|
| Hospital Charge Code |
NDG29443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Blue Shield of California Commercial |
$2.85
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
