|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 5026875515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 5026875515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 6808453911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 6808453911
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 3172253101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| 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 Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6586212701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| 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 Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6586212701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 3172253101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
|
IP
|
$8,804.64
|
|
|
Service Code
|
APR-DRG 8161
|
| Min. Negotiated Rate |
$7,032.13 |
| Max. Negotiated Rate |
$8,804.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,032.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,804.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,877.83
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
|
IP
|
$12,625.04
|
|
|
Service Code
|
APR-DRG 8162
|
| Min. Negotiated Rate |
$10,083.42 |
| Max. Negotiated Rate |
$12,625.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,083.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,625.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,296.09
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
|
IP
|
$61,578.83
|
|
|
Service Code
|
APR-DRG 8164
|
| Min. Negotiated Rate |
$49,182.04 |
| Max. Negotiated Rate |
$61,578.83 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49,182.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$61,578.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55,096.85
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
|
IP
|
$23,031.25
|
|
|
Service Code
|
APR-DRG 8163
|
| Min. Negotiated Rate |
$18,394.69 |
| Max. Negotiated Rate |
$23,031.25 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,394.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23,031.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,606.91
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994081636
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Blue Shield of California Commercial |
$252.99
|
| Rate for Payer: Blue Shield of California Commercial |
$383.73
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$349.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Senior |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$316.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$294.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994081636
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$327.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$320.21
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$349.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Senior |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$316.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$181.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$294.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9999196140
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Blue Shield of California Commercial |
$252.99
|
| Rate for Payer: Blue Shield of California Commercial |
$383.73
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$349.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Senior |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$316.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$294.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9999196140
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA HMO/PPO |
$327.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$320.21
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$349.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Senior |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$316.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$181.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$294.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$399.20
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS POWDER FOR SOLUTION [211543]
|
Facility
|
OP
|
$4,737.11
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.48 |
| Max. Negotiated Rate |
$4,026.54 |
| Rate for Payer: Adventist Health Commercial |
$947.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,288.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$615.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$451.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$410.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$689.86
|
| Rate for Payer: Blue Shield of California Commercial |
$413.76
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cigna of CA HMO |
$3,315.98
|
| Rate for Payer: Cigna of CA PPO |
$3,315.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$513.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$451.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$451.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,315.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$677.29
|
| Rate for Payer: EPIC Health Plan Senior |
$451.53
|
| Rate for Payer: Galaxy Health WC |
$4,026.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.27
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$673.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$410.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$410.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,008.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$743.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$574.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,136.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$517.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$550.04
|
| Rate for Payer: Multiplan Commercial |
$3,789.69
|
| Rate for Payer: Networks By Design Commercial |
$2,368.55
|
| Rate for Payer: Prime Health Services Commercial |
$4,026.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,842.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,842.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,777.84
|
| Rate for Payer: United Healthcare All Other HMO |
$1,730.47
|
| Rate for Payer: United Healthcare HMO Rider |
$1,693.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,551.40
|
| Rate for Payer: Upland Medical Group Pediatric |
$410.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$513.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$451.53
|
| Rate for Payer: Vantage Medical Group Senior |
$451.53
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS POWDER FOR SOLUTION [211543]
|
Facility
|
IP
|
$4,737.11
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$947.42 |
| Max. Negotiated Rate |
$4,026.54 |
| Rate for Payer: Adventist Health Commercial |
$947.42
|
| Rate for Payer: Blue Shield of California Commercial |
$2,401.71
|
| Rate for Payer: Blue Shield of California Commercial |
$3,642.84
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cigna of CA HMO |
$3,315.98
|
| Rate for Payer: Cigna of CA PPO |
$3,315.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,315.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,894.84
|
| Rate for Payer: EPIC Health Plan Senior |
$1,894.84
|
| Rate for Payer: Galaxy Health WC |
$4,026.54
|
| Rate for Payer: Global Benefits Group Commercial |
$2,842.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3,008.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,794.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,136.91
|
| Rate for Payer: Multiplan Commercial |
$3,789.69
|
| Rate for Payer: Networks By Design Commercial |
$2,368.55
|
| Rate for Payer: Prime Health Services Commercial |
$4,026.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,777.84
|
| Rate for Payer: United Healthcare All Other HMO |
$1,730.47
|
| Rate for Payer: United Healthcare HMO Rider |
$1,693.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,551.40
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$2.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3.74
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO |
$3.40
|
| Rate for Payer: Cigna of CA PPO |
$3.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Senior |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Multiplan Commercial |
$3.89
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.78
|
| Rate for Payer: United Healthcare HMO Rider |
$1.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.59
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO |
$3.40
|
| Rate for Payer: Cigna of CA PPO |
$3.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Senior |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$3.89
|
| Rate for Payer: Networks By Design Commercial |
$2.43
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.78
|
| Rate for Payer: United Healthcare HMO Rider |
$1.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.41
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$4.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare HMO Rider |
$2.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA HMO |
$4.41
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$4.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$0.65
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$2.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.41
|
| Rate for Payer: Cigna of CA PPO |
$4.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$3.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare HMO Rider |
$2.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.41
|
| Rate for Payer: Cigna of CA PPO |
$4.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$3.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare HMO Rider |
$2.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
|
|
TRACE ELEMENTS PRETERM [4080052]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.41
|
| Rate for Payer: Cigna of CA PPO |
$4.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.04
|
| Rate for Payer: Networks By Design Commercial |
$3.15
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.36
|
| Rate for Payer: United Healthcare All Other HMO |
$2.30
|
| Rate for Payer: United Healthcare HMO Rider |
$2.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.06
|
|
