|
PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION [95849]
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS J2562
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$425.00 |
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Blue Shield of California Commercial |
$812.83
|
| Rate for Payer: Blue Shield of California Commercial |
$253.50
|
| Rate for Payer: Blue Shield of California Commercial |
$384.50
|
| Rate for Payer: Blue Shield of California Commercial |
$535.90
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna of CA HMO |
$350.00
|
| Rate for Payer: Cigna of CA HMO |
$739.90
|
| Rate for Payer: Cigna of CA PPO |
$739.90
|
| Rate for Payer: Cigna of CA PPO |
$350.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$739.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$350.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$422.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$200.00
|
| Rate for Payer: EPIC Health Plan Senior |
$422.80
|
| Rate for Payer: EPIC Health Plan Senior |
$200.00
|
| Rate for Payer: Galaxy Health WC |
$898.45
|
| Rate for Payer: Galaxy Health WC |
$425.00
|
| Rate for Payer: Global Benefits Group Commercial |
$300.00
|
| Rate for Payer: Global Benefits Group Commercial |
$634.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$671.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$317.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$623.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$295.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$253.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$845.60
|
| Rate for Payer: Multiplan Commercial |
$400.00
|
| Rate for Payer: Networks By Design Commercial |
$250.00
|
| Rate for Payer: Networks By Design Commercial |
$528.50
|
| Rate for Payer: Prime Health Services Commercial |
$425.00
|
| Rate for Payer: Prime Health Services Commercial |
$898.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$396.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$187.65
|
| Rate for Payer: United Healthcare All Other HMO |
$182.65
|
| Rate for Payer: United Healthcare All Other HMO |
$386.12
|
| Rate for Payer: United Healthcare HMO Rider |
$377.77
|
| Rate for Payer: United Healthcare HMO Rider |
$178.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$346.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$163.75
|
|
|
PLEURAL EFFUSION WITH CC
|
Facility
|
IP
|
$96,801.03
|
|
|
Service Code
|
MSDRG 187
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$96,801.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29,985.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$96,801.03
|
| Rate for Payer: EPIC Health Plan Senior |
$64,534.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,667.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,134.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78,614.17
|
| 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
|
|
|
PLEURAL EFFUSION WITH MCC
|
Facility
|
IP
|
$106,904.92
|
|
|
Service Code
|
MSDRG 186
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$106,904.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$47,247.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$106,904.92
|
| Rate for Payer: EPIC Health Plan Senior |
$71,269.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$64,790.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$90,707.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$86,819.75
|
| 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
|
|
|
PLEURAL EFFUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$91,976.23
|
|
|
Service Code
|
MSDRG 188
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$91,976.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,742.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$91,976.23
|
| Rate for Payer: EPIC Health Plan Senior |
$61,317.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55,743.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$78,040.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74,695.85
|
| 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
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
IP
|
$759.38
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.88 |
| Max. Negotiated Rate |
$645.47 |
| Rate for Payer: Adventist Health Commercial |
$151.88
|
| Rate for Payer: Blue Shield of California Commercial |
$385.01
|
| Rate for Payer: Blue Shield of California Commercial |
$583.96
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna of CA HMO |
$531.57
|
| Rate for Payer: Cigna of CA PPO |
$531.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$531.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.75
|
| Rate for Payer: EPIC Health Plan Senior |
$303.75
|
| Rate for Payer: Galaxy Health WC |
$645.47
|
| Rate for Payer: Global Benefits Group Commercial |
$455.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$482.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$448.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$607.50
|
| Rate for Payer: Networks By Design Commercial |
$379.69
|
| Rate for Payer: Prime Health Services Commercial |
$645.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$285.00
|
| Rate for Payer: United Healthcare All Other HMO |
$277.40
|
| Rate for Payer: United Healthcare HMO Rider |
$271.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.70
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
OP
|
$759.38
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.88 |
| Max. Negotiated Rate |
$2,175.34 |
| Rate for Payer: Adventist Health Commercial |
$151.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,175.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$645.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$417.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$569.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$606.87
|
| Rate for Payer: Blue Shield of California Commercial |
$313.77
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna of CA HMO |
$531.57
|
| Rate for Payer: Cigna of CA PPO |
$531.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$645.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$645.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$645.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$531.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.75
|
| Rate for Payer: EPIC Health Plan Senior |
$303.75
|
| Rate for Payer: Galaxy Health WC |
$645.47
|
| Rate for Payer: Global Benefits Group Commercial |
$455.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$341.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$482.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$602.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$448.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$531.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$531.57
|
| Rate for Payer: Multiplan Commercial |
$607.50
|
| Rate for Payer: Networks By Design Commercial |
$379.69
|
| Rate for Payer: Prime Health Services Commercial |
$645.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$285.00
|
| Rate for Payer: United Healthcare All Other HMO |
$277.40
|
| Rate for Payer: United Healthcare HMO Rider |
$271.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$645.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$645.47
|
| Rate for Payer: Vantage Medical Group Senior |
$645.47
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.43 |
| Max. Negotiated Rate |
$927.91 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$927.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.43
|
| Rate for Payer: Blue Shield of California Commercial |
$140.50
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$133.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$178.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$262.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$165.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$196.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$168.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$168.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Blue Shield of California Commercial |
$142.46
|
| Rate for Payer: Blue Shield of California Commercial |
$216.08
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$178.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$165.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Blue Shield of California Commercial |
$142.46
|
| Rate for Payer: Blue Shield of California Commercial |
$216.08
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$178.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$165.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.43 |
| Max. Negotiated Rate |
$927.91 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$927.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.43
|
| Rate for Payer: Blue Shield of California Commercial |
$140.50
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$133.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$178.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$262.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$165.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$196.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$168.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$168.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$98,756.49
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$98,756.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$33,326.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$98,756.49
|
| Rate for Payer: EPIC Health Plan Senior |
$65,837.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,852.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83,793.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80,202.24
|
| 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
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$110,553.27
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$110,553.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53,480.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$110,553.27
|
| Rate for Payer: EPIC Health Plan Senior |
$73,702.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,001.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$93,802.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89,782.65
|
| 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
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$91,938.96
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$91,938.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,678.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$91,938.96
|
| Rate for Payer: EPIC Health Plan Senior |
$61,292.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55,720.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$78,008.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74,665.58
|
| 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
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$107,080.59
|
|
|
Service Code
|
MSDRG 917
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$107,080.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$47,547.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$107,080.59
|
| Rate for Payer: EPIC Health Plan Senior |
$71,387.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$64,897.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$90,856.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$86,962.42
|
| 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
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$94,458.71
|
|
|
Service Code
|
MSDRG 918
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$94,458.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25,983.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$94,458.71
|
| Rate for Payer: EPIC Health Plan Senior |
$62,972.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,247.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$80,146.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76,711.92
|
| 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
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$46,739.28
|
|
|
Service Code
|
APR-DRG 8124
|
| Min. Negotiated Rate |
$37,329.92 |
| Max. Negotiated Rate |
$46,739.28 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37,329.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46,739.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41,819.35
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$11,947.98
|
|
|
Service Code
|
APR-DRG 8122
|
| Min. Negotiated Rate |
$9,542.66 |
| Max. Negotiated Rate |
$11,947.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,542.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,947.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,690.30
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$18,794.82
|
|
|
Service Code
|
APR-DRG 8123
|
| Min. Negotiated Rate |
$15,011.13 |
| Max. Negotiated Rate |
$18,794.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,011.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,794.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16,816.42
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$7,733.28
|
|
|
Service Code
|
APR-DRG 8121
|
| Min. Negotiated Rate |
$6,176.45 |
| Max. Negotiated Rate |
$7,733.28 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,176.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,733.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,919.26
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
IP
|
$23,673.71
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,734.74 |
| Max. Negotiated Rate |
$20,122.65 |
| Rate for Payer: Adventist Health Commercial |
$4,734.74
|
| Rate for Payer: Blue Shield of California Commercial |
$12,002.57
|
| Rate for Payer: Blue Shield of California Commercial |
$18,205.08
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cigna of CA HMO |
$16,571.60
|
| Rate for Payer: Cigna of CA PPO |
$16,571.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16,571.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,469.48
|
| Rate for Payer: EPIC Health Plan Senior |
$9,469.48
|
| Rate for Payer: Galaxy Health WC |
$20,122.65
|
| Rate for Payer: Global Benefits Group Commercial |
$14,204.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15,032.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,967.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,681.69
|
| Rate for Payer: Multiplan Commercial |
$18,938.97
|
| Rate for Payer: Networks By Design Commercial |
$11,836.85
|
| Rate for Payer: Prime Health Services Commercial |
$20,122.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$8,884.74
|
| Rate for Payer: United Healthcare All Other HMO |
$8,648.01
|
| Rate for Payer: United Healthcare HMO Rider |
$8,460.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,753.14
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
OP
|
$23,673.71
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.61 |
| Max. Negotiated Rate |
$20,122.65 |
| Rate for Payer: Adventist Health Commercial |
$4,734.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$261.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$215.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$143.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$273.72
|
| Rate for Payer: Blue Shield of California Commercial |
$154.88
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cigna of CA HMO |
$16,571.60
|
| Rate for Payer: Cigna of CA PPO |
$16,571.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$157.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$157.97
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16,571.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$236.96
|
| Rate for Payer: EPIC Health Plan Senior |
$157.97
|
| Rate for Payer: Galaxy Health WC |
$20,122.65
|
| Rate for Payer: Global Benefits Group Commercial |
$14,204.23
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$235.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$143.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$143.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15,032.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$259.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$201.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,681.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$180.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$192.44
|
| Rate for Payer: Multiplan Commercial |
$18,938.97
|
| Rate for Payer: Networks By Design Commercial |
$11,836.85
|
| Rate for Payer: Prime Health Services Commercial |
$20,122.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14,204.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14,204.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$8,884.74
|
| Rate for Payer: United Healthcare All Other HMO |
$8,648.01
|
| Rate for Payer: United Healthcare HMO Rider |
$8,460.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,753.14
|
| Rate for Payer: Upland Medical Group Pediatric |
$143.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$157.97
|
| Rate for Payer: Vantage Medical Group Senior |
$157.97
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
IP
|
$112.95
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$96.01 |
| Rate for Payer: Adventist Health Commercial |
$22.59
|
| Rate for Payer: Blue Shield of California Commercial |
$57.27
|
| Rate for Payer: Blue Shield of California Commercial |
$86.86
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cigna of CA HMO |
$79.06
|
| Rate for Payer: Cigna of CA PPO |
$79.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.18
|
| Rate for Payer: EPIC Health Plan Senior |
$45.18
|
| Rate for Payer: Galaxy Health WC |
$96.01
|
| Rate for Payer: Global Benefits Group Commercial |
$67.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$71.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.11
|
| Rate for Payer: Multiplan Commercial |
$90.36
|
| Rate for Payer: Networks By Design Commercial |
$56.48
|
| Rate for Payer: Prime Health Services Commercial |
$96.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.39
|
| Rate for Payer: United Healthcare All Other HMO |
$41.26
|
| Rate for Payer: United Healthcare HMO Rider |
$40.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.99
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
OP
|
$112.95
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Adventist Health Commercial |
$22.59
|
| Rate for Payer: Aetna of CA HMO/PPO |
$331.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.42
|
| Rate for Payer: Blue Shield of California Commercial |
$51.02
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cigna of CA HMO |
$79.06
|
| Rate for Payer: Cigna of CA PPO |
$79.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$79.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.18
|
| Rate for Payer: EPIC Health Plan Senior |
$45.18
|
| Rate for Payer: Galaxy Health WC |
$96.01
|
| Rate for Payer: Global Benefits Group Commercial |
$67.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$86.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$71.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$66.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.06
|
| Rate for Payer: Multiplan Commercial |
$90.36
|
| Rate for Payer: Networks By Design Commercial |
$56.48
|
| Rate for Payer: Prime Health Services Commercial |
$96.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$67.77
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$67.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.39
|
| Rate for Payer: United Healthcare All Other HMO |
$41.26
|
| Rate for Payer: United Healthcare HMO Rider |
$40.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.01
|
| Rate for Payer: Vantage Medical Group Senior |
$96.01
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4580286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4580286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
