|
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS
|
Facility
|
IP
|
$60,115.11
|
|
|
Service Code
|
APR-DRG 1301
|
| Min. Negotiated Rate |
$48,012.99 |
| Max. Negotiated Rate |
$60,115.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48,012.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$60,115.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$53,787.20
|
|
|
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS
|
Facility
|
IP
|
$195,074.37
|
|
|
Service Code
|
MSDRG 207
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$195,074.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$195,074.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$193,432.24
|
| Rate for Payer: EPIC Health Plan Senior |
$128,954.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$117,231.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$164,124.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$157,090.42
|
| 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
|
|
|
RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
|
|
RESP ONLY: HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION 30 ML [40810176]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
HCPCS J1644
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$8.82 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC
|
Facility
|
IP
|
$97,242.87
|
|
|
Service Code
|
MSDRG 815
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$97,242.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30,740.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$97,242.87
|
| Rate for Payer: EPIC Health Plan Senior |
$64,828.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,935.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82,509.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78,972.99
|
| 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
|
|
|
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC
|
Facility
|
IP
|
$116,987.54
|
|
|
Service Code
|
MSDRG 814
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$116,987.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$64,473.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$116,987.54
|
| Rate for Payer: EPIC Health Plan Senior |
$77,991.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$70,901.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$99,262.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95,008.06
|
| 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
|
|
|
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$90,464.35
|
|
|
Service Code
|
MSDRG 816
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$90,464.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$19,159.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$90,464.35
|
| Rate for Payer: EPIC Health Plan Senior |
$60,309.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$54,826.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$76,757.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73,468.02
|
| 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
|
|
|
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION [237494]
|
Facility
|
OP
|
$902.28
|
|
|
Service Code
|
HCPCS J9345
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.98 |
| Max. Negotiated Rate |
$766.94 |
| Rate for Payer: Adventist Health Commercial |
$180.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$187.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.69
|
| Rate for Payer: Blue Shield of California Commercial |
$34.69
|
| Rate for Payer: Cash Price |
$406.03
|
| Rate for Payer: Cash Price |
$406.03
|
| Rate for Payer: Cigna of CA HMO |
$631.60
|
| Rate for Payer: Cigna of CA PPO |
$631.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$34.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$631.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.12
|
| Rate for Payer: EPIC Health Plan Senior |
$34.08
|
| Rate for Payer: Galaxy Health WC |
$766.94
|
| Rate for Payer: Global Benefits Group Commercial |
$541.37
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$50.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$572.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.51
|
| Rate for Payer: Multiplan Commercial |
$721.82
|
| Rate for Payer: Networks By Design Commercial |
$451.14
|
| Rate for Payer: Prime Health Services Commercial |
$766.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$541.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$541.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$338.63
|
| Rate for Payer: United Healthcare All Other HMO |
$329.60
|
| Rate for Payer: United Healthcare HMO Rider |
$322.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$295.50
|
| Rate for Payer: Upland Medical Group Pediatric |
$30.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Vantage Medical Group Senior |
$34.08
|
|
|
RETIFANLIMAB-DLWR 500 MG/20 ML INTRAVENOUS SOLUTION [237494]
|
Facility
|
IP
|
$902.28
|
|
|
Service Code
|
HCPCS J9345
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.46 |
| Max. Negotiated Rate |
$766.94 |
| Rate for Payer: Adventist Health Commercial |
$180.46
|
| Rate for Payer: Blue Shield of California Commercial |
$457.46
|
| Rate for Payer: Blue Shield of California Commercial |
$693.85
|
| Rate for Payer: Cash Price |
$406.03
|
| Rate for Payer: Cigna of CA HMO |
$631.60
|
| Rate for Payer: Cigna of CA PPO |
$631.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$631.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$360.91
|
| Rate for Payer: EPIC Health Plan Senior |
$360.91
|
| Rate for Payer: Galaxy Health WC |
$766.94
|
| Rate for Payer: Global Benefits Group Commercial |
$541.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$572.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$532.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$216.55
|
| Rate for Payer: Multiplan Commercial |
$721.82
|
| Rate for Payer: Networks By Design Commercial |
$451.14
|
| Rate for Payer: Prime Health Services Commercial |
$766.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$338.63
|
| Rate for Payer: United Healthcare All Other HMO |
$329.60
|
| Rate for Payer: United Healthcare HMO Rider |
$322.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$295.50
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITH CC
|
Facility
|
IP
|
$141,828.52
|
|
|
Service Code
|
MSDRG 467
|
| Min. Negotiated Rate |
$32,499.00 |
| Max. Negotiated Rate |
$141,828.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$106,912.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$141,828.52
|
| Rate for Payer: EPIC Health Plan Senior |
$94,552.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$85,956.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$120,339.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$115,181.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$36,468.00
|
| Rate for Payer: United Healthcare All Other HMO |
$36,468.00
|
| Rate for Payer: United Healthcare HMO Rider |
$35,474.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$32,499.00
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC
|
Facility
|
IP
|
$171,618.53
|
|
|
Service Code
|
MSDRG 466
|
| Min. Negotiated Rate |
$39,477.00 |
| Max. Negotiated Rate |
$171,618.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$157,806.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$171,618.53
|
| Rate for Payer: EPIC Health Plan Senior |
$114,412.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$104,011.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$145,615.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139,375.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$39,477.00
|
| Rate for Payer: United Healthcare All Other HMO |
$39,477.00
|
| Rate for Payer: United Healthcare HMO Rider |
$45,640.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41,813.00
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$128,012.41
|
|
|
Service Code
|
MSDRG 468
|
| Min. Negotiated Rate |
$28,986.00 |
| Max. Negotiated Rate |
$128,012.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$83,308.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$128,012.41
|
| Rate for Payer: EPIC Health Plan Senior |
$85,341.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$77,583.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108,616.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$103,961.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$39,477.00
|
| Rate for Payer: United Healthcare All Other HMO |
$39,477.00
|
| Rate for Payer: United Healthcare HMO Rider |
$31,639.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28,986.00
|
|
|
REVUMENIB 25 MG TABLET [245038]
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
NDC 7355550000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$83.00 |
| Max. Negotiated Rate |
$352.75 |
| Rate for Payer: Adventist Health Commercial |
$83.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$272.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$352.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$228.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$311.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$266.31
|
| Rate for Payer: Cash Price |
$186.75
|
| Rate for Payer: Cigna of CA HMO |
$290.50
|
| Rate for Payer: Cigna of CA PPO |
$290.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$352.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$352.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$352.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$290.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.00
|
| Rate for Payer: EPIC Health Plan Senior |
$166.00
|
| Rate for Payer: Galaxy Health WC |
$352.75
|
| Rate for Payer: Global Benefits Group Commercial |
$249.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$263.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$150.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$244.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$290.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$290.50
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: Networks By Design Commercial |
$269.75
|
| Rate for Payer: Prime Health Services Commercial |
$352.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$249.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$249.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$207.50
|
| Rate for Payer: United Healthcare All Other HMO |
$207.50
|
| Rate for Payer: United Healthcare HMO Rider |
$207.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$207.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$352.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$352.75
|
| Rate for Payer: Vantage Medical Group Senior |
$352.75
|
|
|
REVUMENIB 25 MG TABLET [245038]
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
NDC 7355550000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$83.00 |
| Max. Negotiated Rate |
$352.75 |
| Rate for Payer: Adventist Health Commercial |
$83.00
|
| Rate for Payer: Blue Shield of California Commercial |
$210.41
|
| Rate for Payer: Blue Shield of California Commercial |
$319.13
|
| Rate for Payer: Cash Price |
$186.75
|
| Rate for Payer: Cigna of CA HMO |
$290.50
|
| Rate for Payer: Cigna of CA PPO |
$290.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$290.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.00
|
| Rate for Payer: EPIC Health Plan Senior |
$166.00
|
| Rate for Payer: Galaxy Health WC |
$352.75
|
| Rate for Payer: Global Benefits Group Commercial |
$249.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$263.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$244.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: Networks By Design Commercial |
$269.75
|
| Rate for Payer: Prime Health Services Commercial |
$352.75
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
|
IP
|
$96.52
|
|
|
Service Code
|
HCPCS J2791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.30 |
| Max. Negotiated Rate |
$82.04 |
| Rate for Payer: Adventist Health Commercial |
$19.30
|
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Blue Shield of California Commercial |
$81.65
|
| Rate for Payer: Blue Shield of California Commercial |
$48.94
|
| Rate for Payer: Blue Shield of California Commercial |
$74.22
|
| Rate for Payer: Blue Shield of California Commercial |
$53.83
|
| Rate for Payer: Cash Price |
$47.78
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cigna of CA HMO |
$67.56
|
| Rate for Payer: Cigna of CA HMO |
$74.33
|
| Rate for Payer: Cigna of CA PPO |
$74.33
|
| Rate for Payer: Cigna of CA PPO |
$67.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.61
|
| Rate for Payer: EPIC Health Plan Senior |
$42.47
|
| Rate for Payer: EPIC Health Plan Senior |
$38.61
|
| Rate for Payer: Galaxy Health WC |
$90.25
|
| Rate for Payer: Galaxy Health WC |
$82.04
|
| Rate for Payer: Global Benefits Group Commercial |
$57.91
|
| Rate for Payer: Global Benefits Group Commercial |
$63.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$61.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$62.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.16
|
| Rate for Payer: Multiplan Commercial |
$84.94
|
| Rate for Payer: Multiplan Commercial |
$77.22
|
| Rate for Payer: Networks By Design Commercial |
$48.26
|
| Rate for Payer: Networks By Design Commercial |
$53.09
|
| Rate for Payer: Prime Health Services Commercial |
$82.04
|
| Rate for Payer: Prime Health Services Commercial |
$90.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.22
|
| Rate for Payer: United Healthcare All Other HMO |
$35.26
|
| Rate for Payer: United Healthcare All Other HMO |
$38.79
|
| Rate for Payer: United Healthcare HMO Rider |
$37.95
|
| Rate for Payer: United Healthcare HMO Rider |
$34.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.61
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
|
OP
|
$106.18
|
|
|
Service Code
|
HCPCS J2791
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$90.25 |
| Rate for Payer: Adventist Health Commercial |
$21.24
|
| Rate for Payer: Adventist Health Commercial |
$19.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$82.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.83
|
| Rate for Payer: Blue Shield of California Commercial |
$12.01
|
| Rate for Payer: Blue Shield of California Commercial |
$12.01
|
| Rate for Payer: Cash Price |
$47.78
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cash Price |
$47.78
|
| Rate for Payer: Cash Price |
$43.43
|
| Rate for Payer: Cigna of CA HMO |
$67.56
|
| Rate for Payer: Cigna of CA HMO |
$74.33
|
| Rate for Payer: Cigna of CA PPO |
$67.56
|
| Rate for Payer: Cigna of CA PPO |
$74.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$82.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$82.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$90.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$74.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.61
|
| Rate for Payer: EPIC Health Plan Senior |
$38.61
|
| Rate for Payer: EPIC Health Plan Senior |
$42.47
|
| Rate for Payer: Galaxy Health WC |
$82.04
|
| Rate for Payer: Galaxy Health WC |
$90.25
|
| Rate for Payer: Global Benefits Group Commercial |
$57.91
|
| Rate for Payer: Global Benefits Group Commercial |
$63.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$67.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$61.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$62.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$67.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.56
|
| Rate for Payer: Multiplan Commercial |
$77.22
|
| Rate for Payer: Multiplan Commercial |
$84.94
|
| Rate for Payer: Networks By Design Commercial |
$48.26
|
| Rate for Payer: Networks By Design Commercial |
$53.09
|
| Rate for Payer: Prime Health Services Commercial |
$90.25
|
| Rate for Payer: Prime Health Services Commercial |
$82.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.22
|
| Rate for Payer: United Healthcare All Other HMO |
$38.79
|
| Rate for Payer: United Healthcare All Other HMO |
$35.26
|
| Rate for Payer: United Healthcare HMO Rider |
$34.50
|
| Rate for Payer: United Healthcare HMO Rider |
$37.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$90.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$82.04
|
| Rate for Payer: Vantage Medical Group Senior |
$90.25
|
| Rate for Payer: Vantage Medical Group Senior |
$82.04
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 6586220768
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.63
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Senior |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare HMO Rider |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 6586220768
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Senior |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7431200640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0761003220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 7431200640
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 4329256000
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| 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 |
$0.03
|
| 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 |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| 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
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0761003220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| 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
|
|
