|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 4354734903
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 5026864211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 5026864215
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 6838209906
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 5026864211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
PAROXETINE 30 MG TABLET [10856]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 6838209906
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 56700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$231.54 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,869.74
|
| Rate for Payer: EPIC Health Plan Senior |
$4,579.83
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,828.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$231.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$261.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,828.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,245.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: Prime Health Services WC |
$6,371.18
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,163.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$8,032.38
|
|
|
Service Code
|
APR-DRG 8441
|
| Min. Negotiated Rate |
$6,415.34 |
| Max. Negotiated Rate |
$8,032.38 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,415.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,032.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,186.87
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$64,370.50
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$51,411.70 |
| Max. Negotiated Rate |
$64,370.50 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51,411.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$64,370.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57,594.66
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$13,943.83
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$11,136.72 |
| Max. Negotiated Rate |
$13,943.83 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,136.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13,943.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12,476.06
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$24,091.73
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$19,241.69 |
| Max. Negotiated Rate |
$24,091.73 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,241.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,091.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21,555.76
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$97,491.29
|
|
|
Service Code
|
MSDRG 543
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$97,491.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$31,164.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$97,491.29
|
| Rate for Payer: EPIC Health Plan Senior |
$64,994.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,085.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,719.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79,174.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$110,595.84
|
|
|
Service Code
|
MSDRG 542
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$110,595.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53,553.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$110,595.84
|
| Rate for Payer: EPIC Health Plan Senior |
$73,730.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,027.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$93,838.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89,817.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$92,639.86
|
|
|
Service Code
|
MSDRG 544
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$92,639.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$22,876.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$92,639.86
|
| Rate for Payer: EPIC Health Plan Senior |
$61,759.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,145.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$78,603.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75,234.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 5343616830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$32.76
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343616801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.34
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$36.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO |
$21.30
|
| Rate for Payer: United Healthcare HMO Rider |
$21.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343616830
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.34
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$36.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO |
$21.30
|
| Rate for Payer: United Healthcare HMO Rider |
$21.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 5343616801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$32.76
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 5343608430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$32.76
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
IP
|
$42.60
|
|
|
Service Code
|
NDC 5343608401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Blue Shield of California Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$32.76
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343608401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.34
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$36.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO |
$21.30
|
| Rate for Payer: United Healthcare HMO Rider |
$21.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
|
OP
|
$42.60
|
|
|
Service Code
|
NDC 5343608430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$36.21 |
| Rate for Payer: Adventist Health Commercial |
$8.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.34
|
| Rate for Payer: Cash Price |
$19.17
|
| Rate for Payer: Cigna of CA HMO |
$29.82
|
| Rate for Payer: Cigna of CA PPO |
$29.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$36.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$29.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Senior |
$17.04
|
| Rate for Payer: Galaxy Health WC |
$36.21
|
| Rate for Payer: Global Benefits Group Commercial |
$25.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$27.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.82
|
| Rate for Payer: Multiplan Commercial |
$34.08
|
| Rate for Payer: Networks By Design Commercial |
$27.69
|
| Rate for Payer: Prime Health Services Commercial |
$36.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.30
|
| Rate for Payer: United Healthcare All Other HMO |
$21.30
|
| Rate for Payer: United Healthcare HMO Rider |
$21.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.21
|
| Rate for Payer: Vantage Medical Group Senior |
$36.21
|
|
|
Pediatric Allo Related BMT
|
Facility
|
IP
|
$245,000.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$150,000.00 |
| Max. Negotiated Rate |
$245,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$221,772.00
|
| Rate for Payer: Blue Shield of California Transplant |
$150,000.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$245,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$206,790.00
|
|
|
Pediatric Allo-Related Transplant - Inpatient
|
Facility
|
IP
|
$200,000.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$172,490.00 |
| Max. Negotiated Rate |
$200,000.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$175,000.00
|
| Rate for Payer: Blue Distinction Transplant |
$172,490.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$200,000.00
|
|
|
Pediatric Allo-Related Transplant - Outpatient
|
Facility
|
OP
|
$131,250.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$131,250.00 |
| Max. Negotiated Rate |
$131,250.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$131,250.00
|
|
