|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
|
OP
|
$963.40
|
|
|
Service Code
|
NDC 0069098038
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$192.68 |
| Max. Negotiated Rate |
$818.89 |
| Rate for Payer: Adventist Health Commercial |
$192.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$631.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$818.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$529.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$722.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$618.21
|
| Rate for Payer: Cash Price |
$433.53
|
| Rate for Payer: Cigna of CA HMO |
$674.38
|
| Rate for Payer: Cigna of CA PPO |
$674.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$818.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$818.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$818.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$674.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$385.36
|
| Rate for Payer: EPIC Health Plan Senior |
$385.36
|
| Rate for Payer: Galaxy Health WC |
$818.89
|
| Rate for Payer: Global Benefits Group Commercial |
$578.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$611.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$349.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$568.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$674.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$674.38
|
| Rate for Payer: Multiplan Commercial |
$770.72
|
| Rate for Payer: Networks By Design Commercial |
$626.21
|
| Rate for Payer: Prime Health Services Commercial |
$818.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$578.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$578.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$481.70
|
| Rate for Payer: United Healthcare All Other HMO |
$481.70
|
| Rate for Payer: United Healthcare HMO Rider |
$481.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$481.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$818.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$818.89
|
| Rate for Payer: Vantage Medical Group Senior |
$818.89
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| 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: 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 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 |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| 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
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 15002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$90.69 |
| 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 |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,568.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1,045.63
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,558.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$90.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$102.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,330.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,197.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$950.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT S2900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,753.44 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,753.44
|
| Rate for Payer: Blue Shield of California Commercial |
$7,196.06
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$252.69 |
| 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 |
$5,354.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,926.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,569.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,354.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,926.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,569.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,890.43
|
| Rate for Payer: EPIC Health Plan Senior |
$3,926.96
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$5,854.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$252.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,569.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$285.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,997.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,498.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,783.75
|
| Rate for Payer: Multiplan WC |
$5,551.91
|
| Rate for Payer: Prime Health Services WC |
$5,495.25
|
| 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 |
$3,569.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,354.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,926.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3,569.96
|
|
|
SUTURE OF INFRAPATELLAR TENDON; PRIMARY
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 27380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$155.74 |
| 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 |
$13,999.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9,332.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,641.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,912.69
|
| Rate for Payer: Blue Shield of California Commercial |
$1,924.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,265.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,332.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,398.95
|
| Rate for Payer: EPIC Health Plan Senior |
$10,265.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$15,305.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$155.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,332.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$176.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,065.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,759.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12,505.82
|
| Rate for Payer: Multiplan WC |
$14,462.30
|
| Rate for Payer: Prime Health Services WC |
$14,314.73
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$9,332.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Vantage Medical Group Senior |
$9,332.70
|
|
|
SUZETRIGINE 50 MG TABLET [244603]
|
Facility
|
IP
|
$18.60
|
|
|
Service Code
|
HCPCS C9818
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Adventist Health Commercial |
$3.72
|
| Rate for Payer: Blue Shield of California Commercial |
$14.30
|
| Rate for Payer: Blue Shield of California Commercial |
$9.43
|
| Rate for Payer: Cash Price |
$8.37
|
| Rate for Payer: Cigna of CA HMO |
$13.02
|
| Rate for Payer: Cigna of CA PPO |
$13.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.44
|
| Rate for Payer: EPIC Health Plan Senior |
$7.44
|
| Rate for Payer: Galaxy Health WC |
$15.81
|
| Rate for Payer: Global Benefits Group Commercial |
$11.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Multiplan Commercial |
$14.88
|
| Rate for Payer: Networks By Design Commercial |
$9.30
|
| Rate for Payer: Prime Health Services Commercial |
$15.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO |
$6.79
|
| Rate for Payer: United Healthcare HMO Rider |
$6.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.09
|
|
|
SUZETRIGINE 50 MG TABLET [244603]
|
Facility
|
OP
|
$18.60
|
|
|
Service Code
|
HCPCS C9818
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Adventist Health Commercial |
$3.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.94
|
| Rate for Payer: Cash Price |
$8.37
|
| Rate for Payer: Cash Price |
$8.37
|
| Rate for Payer: Cigna of CA HMO |
$13.02
|
| Rate for Payer: Cigna of CA PPO |
$13.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$15.81
|
| Rate for Payer: Global Benefits Group Commercial |
$11.16
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$14.88
|
| Rate for Payer: Networks By Design Commercial |
$9.30
|
| Rate for Payer: Prime Health Services Commercial |
$15.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.98
|
| Rate for Payer: United Healthcare All Other HMO |
$6.79
|
| Rate for Payer: United Healthcare HMO Rider |
$6.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.09
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$18,492.99
|
|
|
Service Code
|
APR-DRG 2043
|
| Min. Negotiated Rate |
$14,770.06 |
| Max. Negotiated Rate |
$18,492.99 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,770.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,492.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16,546.35
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$12,024.11
|
|
|
Service Code
|
APR-DRG 2041
|
| Min. Negotiated Rate |
$9,603.47 |
| Max. Negotiated Rate |
$12,024.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,603.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,024.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,758.42
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$38,565.19
|
|
|
Service Code
|
APR-DRG 2044
|
| Min. Negotiated Rate |
$30,801.41 |
| Max. Negotiated Rate |
$38,565.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30,801.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38,565.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34,505.70
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$14,294.61
|
|
|
Service Code
|
APR-DRG 2042
|
| Min. Negotiated Rate |
$11,416.88 |
| Max. Negotiated Rate |
$14,294.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,416.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,294.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12,789.92
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$94,716.01
|
|
|
Service Code
|
MSDRG 312
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$94,716.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$26,423.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$94,716.01
|
| Rate for Payer: EPIC Health Plan Senior |
$63,144.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,403.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$80,365.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76,920.88
|
| 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
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 4580239000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$1.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.38
|
| Rate for Payer: Global Benefits Group Commercial |
$1.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
| Rate for Payer: Networks By Design Commercial |
$1.82
|
| Rate for Payer: Prime Health Services Commercial |
$2.38
|
|
|
TACROLIMUS 0.03 % TOPICAL OINTMENT [29442]
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 4580239000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.80
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cigna of CA HMO |
$1.96
|
| Rate for Payer: Cigna of CA PPO |
$1.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.38
|
| Rate for Payer: Global Benefits Group Commercial |
$1.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.96
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
| Rate for Payer: Networks By Design Commercial |
$1.82
|
| Rate for Payer: Prime Health Services Commercial |
$2.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.40
|
| Rate for Payer: United Healthcare All Other HMO |
$1.40
|
| Rate for Payer: United Healthcare HMO Rider |
$1.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Vantage Medical Group Senior |
$2.38
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 0168041660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.75
|
| Rate for Payer: Blue Shield of California Commercial |
$4.17
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna of CA HMO |
$3.79
|
| Rate for Payer: Cigna of CA PPO |
$3.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.17
|
| Rate for Payer: EPIC Health Plan Senior |
$2.17
|
| Rate for Payer: Galaxy Health WC |
$4.61
|
| Rate for Payer: Global Benefits Group Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.61
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 0168041660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna of CA HMO |
$3.79
|
| Rate for Payer: Cigna of CA PPO |
$3.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.17
|
| Rate for Payer: EPIC Health Plan Senior |
$2.17
|
| Rate for Payer: Galaxy Health WC |
$4.61
|
| Rate for Payer: Global Benefits Group Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.71
|
| Rate for Payer: United Healthcare All Other HMO |
$2.71
|
| Rate for Payer: United Healthcare HMO Rider |
$2.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.61
|
| Rate for Payer: Vantage Medical Group Senior |
$4.61
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 0168041630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$2.75
|
| Rate for Payer: Blue Shield of California Commercial |
$4.17
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna of CA HMO |
$3.79
|
| Rate for Payer: Cigna of CA PPO |
$3.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.17
|
| Rate for Payer: EPIC Health Plan Senior |
$2.17
|
| Rate for Payer: Galaxy Health WC |
$4.61
|
| Rate for Payer: Global Benefits Group Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.61
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 1672942210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.57
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Vantage Medical Group Senior |
$3.40
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 6846253465
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.08
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 4580270001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.54
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 0168041630
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.48
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna of CA HMO |
$3.79
|
| Rate for Payer: Cigna of CA PPO |
$3.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.17
|
| Rate for Payer: EPIC Health Plan Senior |
$2.17
|
| Rate for Payer: Galaxy Health WC |
$4.61
|
| Rate for Payer: Global Benefits Group Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.71
|
| Rate for Payer: United Healthcare All Other HMO |
$2.71
|
| Rate for Payer: United Healthcare HMO Rider |
$2.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.61
|
| Rate for Payer: Vantage Medical Group Senior |
$4.61
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 4580270001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
|
TACROLIMUS 0.1 % TOPICAL OINTMENT [29443]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 1672942210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Adventist Health Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$3.08
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna of CA HMO |
$2.80
|
| Rate for Payer: Cigna of CA PPO |
$2.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: EPIC Health Plan Senior |
$1.60
|
| Rate for Payer: Galaxy Health WC |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$2.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Networks By Design Commercial |
$2.60
|
| Rate for Payer: Prime Health Services Commercial |
$3.40
|
|
