|
TRACE ELEMENTS PRETERM [4080052]
|
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
|
|
|
TRACHEOSTOMA REVISION; SIMPLE, WITHOUT FLAP ROTATION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 31613
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$377.78 |
| Max. Negotiated Rate |
$32,312.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,312.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,264.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,897.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2,574.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,690.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,264.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,035.98
|
| Rate for Payer: EPIC Health Plan Senior |
$4,690.65
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,993.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$377.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,264.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$427.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,969.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,372.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,714.07
|
| Rate for Payer: Multiplan WC |
$6,565.51
|
| Rate for Payer: Prime Health Services WC |
$6,498.52
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,264.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,396.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,690.65
|
| Rate for Payer: Vantage Medical Group Senior |
$4,264.23
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC
|
Facility
|
IP
|
$154,061.80
|
|
|
Service Code
|
MSDRG 012
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$154,061.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$127,812.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$154,061.80
|
| Rate for Payer: EPIC Health Plan Senior |
$102,707.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$93,370.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$130,719.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$125,116.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC
|
Facility
|
IP
|
$176,031.67
|
|
|
Service Code
|
MSDRG 011
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$176,031.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$165,346.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$176,031.67
|
| Rate for Payer: EPIC Health Plan Senior |
$117,354.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$106,685.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$149,360.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$142,959.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$130,386.65
|
|
|
Service Code
|
MSDRG 013
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$130,386.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$87,364.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$130,386.65
|
| Rate for Payer: EPIC Health Plan Senior |
$86,924.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$79,022.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$110,631.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$105,889.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$419,919.04
|
|
|
Service Code
|
MSDRG 004
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$419,919.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$419,919.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$325,040.30
|
| Rate for Payer: EPIC Health Plan Senior |
$216,693.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$196,994.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$275,791.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$263,972.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$157,667.57
|
|
|
Service Code
|
APR-DRG 0042
|
| Min. Negotiated Rate |
$125,926.60 |
| Max. Negotiated Rate |
$157,667.57 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$125,926.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$157,667.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$141,070.98
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$252,821.73
|
|
|
Service Code
|
APR-DRG 0043
|
| Min. Negotiated Rate |
$201,924.73 |
| Max. Negotiated Rate |
$252,821.73 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$201,924.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$252,821.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$226,208.92
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$494,407.11
|
|
|
Service Code
|
APR-DRG 0044
|
| Min. Negotiated Rate |
$394,875.15 |
| Max. Negotiated Rate |
$494,407.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$394,875.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$494,407.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$442,364.26
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$111,705.67
|
|
|
Service Code
|
APR-DRG 0041
|
| Min. Negotiated Rate |
$89,217.56 |
| Max. Negotiated Rate |
$111,705.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$89,217.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$111,705.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$99,947.18
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$64,577.26
|
|
|
Service Code
|
APR-DRG 0051
|
| Min. Negotiated Rate |
$51,576.84 |
| Max. Negotiated Rate |
$64,577.26 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51,576.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$64,577.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57,779.65
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$351,693.69
|
|
|
Service Code
|
APR-DRG 0054
|
| Min. Negotiated Rate |
$280,892.19 |
| Max. Negotiated Rate |
$351,693.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$280,892.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$351,693.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$314,673.30
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$128,178.31
|
|
|
Service Code
|
APR-DRG 0052
|
| Min. Negotiated Rate |
$102,373.99 |
| Max. Negotiated Rate |
$128,178.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$102,373.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$128,178.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$114,685.86
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE
|
Facility
|
IP
|
$191,409.59
|
|
|
Service Code
|
APR-DRG 0053
|
| Min. Negotiated Rate |
$152,875.82 |
| Max. Negotiated Rate |
$191,409.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$152,875.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$191,409.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$171,261.21
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 5107999101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 5766437708
|
| 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
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 5107999120
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 5107999101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 5766437708
|
| 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
|
|
|
TRAMADOL 50 MG TABLET [14632]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 5107999120
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
TRAMADOL ER 100 MG TABLET,EXTENDED RELEASE 24 HR [70352]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 4733585983
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$2.26
|
| Rate for Payer: Cigna of CA PPO |
$2.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.10
|
| Rate for Payer: Prime Health Services Commercial |
$2.75
|
|
|
TRAMADOL ER 100 MG TABLET,EXTENDED RELEASE 24 HR [70352]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 4733585983
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Adventist Health Commercial |
$0.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Cash Price |
$1.45
|
| Rate for Payer: Cigna of CA HMO |
$2.26
|
| Rate for Payer: Cigna of CA PPO |
$2.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.75
|
| Rate for Payer: Global Benefits Group Commercial |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$2.58
|
| Rate for Payer: Networks By Design Commercial |
$2.10
|
| Rate for Payer: Prime Health Services Commercial |
$2.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Vantage Medical Group Senior |
$2.75
|
|
|
TRAMETINIB 0.5 MG TABLET [202203]
|
Facility
|
IP
|
$214.80
|
|
|
Service Code
|
NDC 0078110515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.96 |
| Max. Negotiated Rate |
$182.58 |
| Rate for Payer: Adventist Health Commercial |
$42.96
|
| Rate for Payer: Blue Shield of California Commercial |
$108.90
|
| Rate for Payer: Blue Shield of California Commercial |
$165.18
|
| Rate for Payer: Cash Price |
$96.66
|
| Rate for Payer: Cigna of CA HMO |
$150.36
|
| Rate for Payer: Cigna of CA PPO |
$150.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$150.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.92
|
| Rate for Payer: EPIC Health Plan Senior |
$85.92
|
| Rate for Payer: Galaxy Health WC |
$182.58
|
| Rate for Payer: Global Benefits Group Commercial |
$128.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$136.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$126.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.55
|
| Rate for Payer: Multiplan Commercial |
$171.84
|
| Rate for Payer: Networks By Design Commercial |
$139.62
|
| Rate for Payer: Prime Health Services Commercial |
$182.58
|
|
|
TRAMETINIB 0.5 MG TABLET [202203]
|
Facility
|
OP
|
$214.80
|
|
|
Service Code
|
NDC 0078110515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.96 |
| Max. Negotiated Rate |
$182.58 |
| Rate for Payer: Adventist Health Commercial |
$42.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$140.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$182.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$118.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$161.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.84
|
| Rate for Payer: Cash Price |
$96.66
|
| Rate for Payer: Cigna of CA HMO |
$150.36
|
| Rate for Payer: Cigna of CA PPO |
$150.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$182.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$182.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$150.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.92
|
| Rate for Payer: EPIC Health Plan Senior |
$85.92
|
| Rate for Payer: Galaxy Health WC |
$182.58
|
| Rate for Payer: Global Benefits Group Commercial |
$128.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$136.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$77.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$126.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$150.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$150.36
|
| Rate for Payer: Multiplan Commercial |
$171.84
|
| Rate for Payer: Networks By Design Commercial |
$139.62
|
| Rate for Payer: Prime Health Services Commercial |
$182.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$128.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$128.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$107.40
|
| Rate for Payer: United Healthcare All Other HMO |
$107.40
|
| Rate for Payer: United Healthcare HMO Rider |
$107.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$107.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$182.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.58
|
| Rate for Payer: Vantage Medical Group Senior |
$182.58
|
|
|
TRAMETINIB 2 MG TABLET [202204]
|
Facility
|
IP
|
$731.08
|
|
|
Service Code
|
NDC 0078111215
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$146.22 |
| Max. Negotiated Rate |
$621.42 |
| Rate for Payer: Adventist Health Commercial |
$146.22
|
| Rate for Payer: Blue Shield of California Commercial |
$370.66
|
| Rate for Payer: Blue Shield of California Commercial |
$562.20
|
| Rate for Payer: Cash Price |
$328.99
|
| Rate for Payer: Cigna of CA HMO |
$511.76
|
| Rate for Payer: Cigna of CA PPO |
$511.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$511.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.43
|
| Rate for Payer: EPIC Health Plan Senior |
$292.43
|
| Rate for Payer: Galaxy Health WC |
$621.42
|
| Rate for Payer: Global Benefits Group Commercial |
$438.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$464.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$431.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$175.46
|
| Rate for Payer: Multiplan Commercial |
$584.86
|
| Rate for Payer: Networks By Design Commercial |
$475.20
|
| Rate for Payer: Prime Health Services Commercial |
$621.42
|
|
