|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$274.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$297.30
|
| Rate for Payer: Blue Distinction Transplant |
$299.40
|
| Rate for Payer: Blue Shield of California Commercial |
$367.76
|
| Rate for Payer: Blue Shield of California EPN |
$291.42
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Media |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$374.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Blue Shield of California Commercial |
$355.29
|
| Rate for Payer: Blue Shield of California EPN |
$255.49
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
NDC196140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$274.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$297.30
|
| Rate for Payer: Blue Distinction Transplant |
$299.40
|
| Rate for Payer: Blue Shield of California Commercial |
$367.76
|
| Rate for Payer: Blue Shield of California EPN |
$291.42
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Media |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$374.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
NDC196140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.76 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Blue Shield of California Commercial |
$355.29
|
| Rate for Payer: Blue Shield of California EPN |
$255.49
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]
|
Facility
|
IP
|
$3,866.89
|
|
|
Service Code
|
CPT J9352
|
| Hospital Charge Code |
ERX211543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$928.05 |
| Max. Negotiated Rate |
$3,286.86 |
| Rate for Payer: Blue Shield of California Commercial |
$2,753.23
|
| Rate for Payer: Blue Shield of California EPN |
$1,979.85
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Cigna of CA HMO |
$2,706.82
|
| Rate for Payer: Cigna of CA PPO |
$2,706.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,546.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,546.76
|
| Rate for Payer: Galaxy Health WC |
$3,286.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2,320.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,579.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,473.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$928.05
|
| Rate for Payer: Multiplan Commercial |
$3,093.51
|
| Rate for Payer: Networks By Design Commercial |
$1,933.44
|
| Rate for Payer: Prime Health Services Commercial |
$3,286.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,460.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1,426.11
|
| Rate for Payer: United Healthcare HMO Rider |
$1,395.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,276.07
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]
|
Facility
|
OP
|
$3,866.89
|
|
|
Service Code
|
CPT J9352
|
| Hospital Charge Code |
ERX211543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.40 |
| Max. Negotiated Rate |
$3,286.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,128.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$423.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$372.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$372.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$575.54
|
| Rate for Payer: Blue Distinction Transplant |
$2,320.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,849.90
|
| Rate for Payer: Blue Shield of California EPN |
$364.39
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Cigna of CA HMO |
$2,706.82
|
| Rate for Payer: Cigna of CA PPO |
$2,706.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.60
|
| Rate for Payer: Dignity Health Media |
$338.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$372.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$338.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$338.40
|
| Rate for Payer: Galaxy Health WC |
$3,286.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2,320.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,900.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$554.97
|
| Rate for Payer: Heritage Provider Network Transplant |
$554.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$548.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$548.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$338.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,579.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$651.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$338.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$928.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$426.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$453.45
|
| Rate for Payer: Multiplan Commercial |
$3,093.51
|
| Rate for Payer: Networks By Design Commercial |
$1,933.44
|
| Rate for Payer: Prime Health Services Commercial |
$3,286.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,320.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,320.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,933.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,933.44
|
| Rate for Payer: United Healthcare HMO Rider |
$1,933.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,933.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$507.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$372.24
|
| Rate for Payer: Vantage Medical Group Senior |
$338.40
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
NDG18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Blue Shield of California Commercial |
$3.46
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.89
|
| Rate for Payer: Networks By Design Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
NDG18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.90
|
| Rate for Payer: Blue Distinction Transplant |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.58
|
| Rate for Payer: Blue Shield of California EPN |
$2.84
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO |
$3.11
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: Dignity Health Media |
$4.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.89
|
| Rate for Payer: Networks By Design Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO |
$2.43
|
| Rate for Payer: United Healthcare HMO Rider |
$2.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
ERX4080051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.75
|
| Rate for Payer: Blue Distinction Transplant |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.68
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.03
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
ERX4080051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-53
|
| Hospital Charge Code |
ERX4080053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-53
|
| Hospital Charge Code |
ERX4080053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.75
|
| Rate for Payer: Blue Distinction Transplant |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.68
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.03
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS PRETERM [4080052]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-52
|
| Hospital Charge Code |
ERX4080052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.75
|
| Rate for Payer: Blue Distinction Transplant |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.68
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.03
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS PRETERM [4080052]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-52
|
| Hospital Charge Code |
ERX4080052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$234,900.10
|
|
|
Service Code
|
APR-DRG 0044
|
| Min. Negotiated Rate |
$180,193.10 |
| Max. Negotiated Rate |
$234,900.10 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$180,193.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$234,900.10
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$73,798.98
|
|
|
Service Code
|
APR-DRG 0041
|
| Min. Negotiated Rate |
$56,611.59 |
| Max. Negotiated Rate |
$73,798.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$56,611.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73,798.98
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$160,748.19
|
|
|
Service Code
|
APR-DRG 0043
|
| Min. Negotiated Rate |
$123,310.78 |
| Max. Negotiated Rate |
$160,748.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$123,310.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160,748.19
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$110,516.71
|
|
|
Service Code
|
APR-DRG 0042
|
| Min. Negotiated Rate |
$84,777.95 |
| Max. Negotiated Rate |
$110,516.71 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$84,777.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110,516.71
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$154,803.54
|
|
|
Service Code
|
APR-DRG 0054
|
| Min. Negotiated Rate |
$118,750.61 |
| Max. Negotiated Rate |
$154,803.54 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$118,750.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154,803.54
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$83,441.29
|
|
|
Service Code
|
APR-DRG 0052
|
| Min. Negotiated Rate |
$64,008.26 |
| Max. Negotiated Rate |
$83,441.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$64,008.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$83,441.29
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$69,290.85
|
|
|
Service Code
|
APR-DRG 0051
|
| Min. Negotiated Rate |
$53,153.38 |
| Max. Negotiated Rate |
$69,290.85 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53,153.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69,290.85
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$113,996.24
|
|
|
Service Code
|
APR-DRG 0053
|
| Min. Negotiated Rate |
$87,447.11 |
| Max. Negotiated Rate |
$113,996.24 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$87,447.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$113,996.24
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 57664-377-08
|
| Hospital Charge Code |
1711651
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| 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 |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| 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 |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 68084-808-01
|
| Hospital Charge Code |
1711651
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 68084-808-11
|
| Hospital Charge Code |
1711651
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
