|
TROPICAMIDE 0.5 % EYE DROPS [8249]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 6131435401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.20
|
| Rate for Payer: Cigna of CA PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Senior |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
| Rate for Payer: Networks By Design Commercial |
$1.11
|
| Rate for Payer: Prime Health Services Commercial |
$1.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO |
$0.86
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1.45
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 7006912101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.58
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 7006912101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 6131435502
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.57
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO |
$1.23
|
| Rate for Payer: United Healthcare HMO Rider |
$1.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Vantage Medical Group Senior |
$2.08
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 6131435502
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
|
|
TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]
|
Facility
|
OP
|
$16.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Adventist Health Commercial |
$3.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.60
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cigna of CA HMO |
$11.76
|
| Rate for Payer: Cigna of CA PPO |
$11.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.72
|
| Rate for Payer: EPIC Health Plan Senior |
$6.72
|
| Rate for Payer: Galaxy Health WC |
$14.28
|
| Rate for Payer: Global Benefits Group Commercial |
$10.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.76
|
| Rate for Payer: Multiplan Commercial |
$13.44
|
| Rate for Payer: Networks By Design Commercial |
$8.40
|
| Rate for Payer: Prime Health Services Commercial |
$14.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.31
|
| Rate for Payer: United Healthcare All Other HMO |
$6.14
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.28
|
| Rate for Payer: Vantage Medical Group Senior |
$14.28
|
|
|
TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]
|
Facility
|
IP
|
$16.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Adventist Health Commercial |
$3.36
|
| Rate for Payer: Blue Shield of California Commercial |
$12.92
|
| Rate for Payer: Blue Shield of California Commercial |
$8.52
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cigna of CA HMO |
$11.76
|
| Rate for Payer: Cigna of CA PPO |
$11.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.72
|
| Rate for Payer: EPIC Health Plan Senior |
$6.72
|
| Rate for Payer: Galaxy Health WC |
$14.28
|
| Rate for Payer: Global Benefits Group Commercial |
$10.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.03
|
| Rate for Payer: Multiplan Commercial |
$13.44
|
| Rate for Payer: Networks By Design Commercial |
$8.40
|
| Rate for Payer: Prime Health Services Commercial |
$14.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.31
|
| Rate for Payer: United Healthcare All Other HMO |
$6.14
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.50
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]
|
Facility
|
OP
|
$207.91
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$176.72 |
| Rate for Payer: Adventist Health Commercial |
$41.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$32.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.66
|
| Rate for Payer: Cash Price |
$93.56
|
| Rate for Payer: Cash Price |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$145.54
|
| Rate for Payer: Cigna of CA PPO |
$145.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$145.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.94
|
| Rate for Payer: EPIC Health Plan Senior |
$11.96
|
| Rate for Payer: Galaxy Health WC |
$176.72
|
| Rate for Payer: Global Benefits Group Commercial |
$124.75
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$17.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$132.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$35.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.57
|
| Rate for Payer: Multiplan Commercial |
$166.33
|
| Rate for Payer: Networks By Design Commercial |
$103.95
|
| Rate for Payer: Prime Health Services Commercial |
$176.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$124.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$124.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.03
|
| Rate for Payer: United Healthcare All Other HMO |
$75.95
|
| Rate for Payer: United Healthcare HMO Rider |
$74.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.09
|
| Rate for Payer: Upland Medical Group Pediatric |
$10.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.96
|
| Rate for Payer: Vantage Medical Group Senior |
$11.96
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]
|
Facility
|
IP
|
$207.91
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$176.72 |
| Rate for Payer: Adventist Health Commercial |
$41.58
|
| Rate for Payer: Blue Shield of California Commercial |
$105.41
|
| Rate for Payer: Blue Shield of California Commercial |
$159.88
|
| Rate for Payer: Cash Price |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$145.54
|
| Rate for Payer: Cigna of CA PPO |
$145.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$145.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.16
|
| Rate for Payer: EPIC Health Plan Senior |
$83.16
|
| Rate for Payer: Galaxy Health WC |
$176.72
|
| Rate for Payer: Global Benefits Group Commercial |
$124.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$132.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$122.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Multiplan Commercial |
$166.33
|
| Rate for Payer: Networks By Design Commercial |
$103.95
|
| Rate for Payer: Prime Health Services Commercial |
$176.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.03
|
| Rate for Payer: United Healthcare All Other HMO |
$75.95
|
| Rate for Payer: United Healthcare HMO Rider |
$74.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.09
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
OP
|
$151.39
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
901700020
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$128.68 |
| Rate for Payer: Adventist Health Commercial |
$30.28
|
| Rate for Payer: Adventist Health Commercial |
$23.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$52.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$52.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.45
|
| Rate for Payer: Blue Shield of California Commercial |
$54.39
|
| Rate for Payer: Blue Shield of California Commercial |
$82.23
|
| Rate for Payer: Blue Shield of California Commercial |
$69.79
|
| Rate for Payer: Blue Shield of California Commercial |
$105.52
|
| Rate for Payer: Cash Price |
$68.13
|
| Rate for Payer: Cash Price |
$68.13
|
| Rate for Payer: Cash Price |
$53.09
|
| Rate for Payer: Cash Price |
$53.09
|
| Rate for Payer: Cigna of CA HMO |
$75.51
|
| Rate for Payer: Cigna of CA HMO |
$96.89
|
| Rate for Payer: Cigna of CA PPO |
$112.03
|
| Rate for Payer: Cigna of CA PPO |
$87.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$105.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.38
|
| Rate for Payer: EPIC Health Plan Senior |
$40.92
|
| Rate for Payer: EPIC Health Plan Senior |
$40.92
|
| Rate for Payer: Galaxy Health WC |
$128.68
|
| Rate for Payer: Galaxy Health WC |
$100.28
|
| Rate for Payer: Global Benefits Group Commercial |
$90.83
|
| Rate for Payer: Global Benefits Group Commercial |
$70.79
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$61.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$61.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$96.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$52.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$52.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Multiplan Commercial |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$121.11
|
| Rate for Payer: Networks By Design Commercial |
$76.69
|
| Rate for Payer: Networks By Design Commercial |
$98.40
|
| Rate for Payer: Prime Health Services Commercial |
$100.28
|
| Rate for Payer: Prime Health Services Commercial |
$128.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.44
|
| Rate for Payer: United Healthcare All Other HMO |
$20.44
|
| Rate for Payer: United Healthcare All Other HMO |
$20.44
|
| Rate for Payer: United Healthcare HMO Rider |
$20.44
|
| Rate for Payer: United Healthcare HMO Rider |
$20.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.44
|
| Rate for Payer: Upland Medical Group Pediatric |
$37.20
|
| Rate for Payer: Upland Medical Group Pediatric |
$37.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
IP
|
$117.98
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
901700020
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$23.60 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Adventist Health Commercial |
$23.60
|
| Rate for Payer: Adventist Health Commercial |
$30.28
|
| Rate for Payer: Cash Price |
$53.09
|
| Rate for Payer: Cash Price |
$68.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$105.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.56
|
| Rate for Payer: EPIC Health Plan Senior |
$60.56
|
| Rate for Payer: EPIC Health Plan Senior |
$47.19
|
| Rate for Payer: Galaxy Health WC |
$128.68
|
| Rate for Payer: Galaxy Health WC |
$100.28
|
| Rate for Payer: Global Benefits Group Commercial |
$70.79
|
| Rate for Payer: Global Benefits Group Commercial |
$90.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$96.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$89.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.32
|
| Rate for Payer: Multiplan Commercial |
$121.11
|
| Rate for Payer: Multiplan Commercial |
$94.38
|
| Rate for Payer: Networks By Design Commercial |
$76.69
|
| Rate for Payer: Networks By Design Commercial |
$98.40
|
| Rate for Payer: Prime Health Services Commercial |
$128.68
|
| Rate for Payer: Prime Health Services Commercial |
$100.28
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
IP
|
$271.90
|
|
|
Service Code
|
NDC 5114400212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.38 |
| Max. Negotiated Rate |
$231.12 |
| Rate for Payer: Adventist Health Commercial |
$54.38
|
| Rate for Payer: Blue Shield of California Commercial |
$137.85
|
| Rate for Payer: Blue Shield of California Commercial |
$209.09
|
| Rate for Payer: Cash Price |
$122.35
|
| Rate for Payer: Cigna of CA HMO |
$190.33
|
| Rate for Payer: Cigna of CA PPO |
$190.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.76
|
| Rate for Payer: EPIC Health Plan Senior |
$108.76
|
| Rate for Payer: Galaxy Health WC |
$231.12
|
| Rate for Payer: Global Benefits Group Commercial |
$163.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.26
|
| Rate for Payer: Multiplan Commercial |
$217.52
|
| Rate for Payer: Networks By Design Commercial |
$176.74
|
| Rate for Payer: Prime Health Services Commercial |
$231.12
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
OP
|
$271.90
|
|
|
Service Code
|
NDC 5114400212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.38 |
| Max. Negotiated Rate |
$231.12 |
| Rate for Payer: Adventist Health Commercial |
$54.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$178.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$203.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$174.48
|
| Rate for Payer: Cash Price |
$122.35
|
| Rate for Payer: Cigna of CA HMO |
$190.33
|
| Rate for Payer: Cigna of CA PPO |
$190.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$231.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.76
|
| Rate for Payer: EPIC Health Plan Senior |
$108.76
|
| Rate for Payer: Galaxy Health WC |
$231.12
|
| Rate for Payer: Global Benefits Group Commercial |
$163.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$98.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$190.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$190.33
|
| Rate for Payer: Multiplan Commercial |
$217.52
|
| Rate for Payer: Networks By Design Commercial |
$176.74
|
| Rate for Payer: Prime Health Services Commercial |
$231.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$135.95
|
| Rate for Payer: United Healthcare All Other HMO |
$135.95
|
| Rate for Payer: United Healthcare HMO Rider |
$135.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$135.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.12
|
| Rate for Payer: Vantage Medical Group Senior |
$231.12
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
IP
|
$135.22
|
|
|
Service Code
|
NDC 5114400160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$114.94 |
| Rate for Payer: Adventist Health Commercial |
$27.04
|
| Rate for Payer: Blue Shield of California Commercial |
$103.98
|
| Rate for Payer: Blue Shield of California Commercial |
$68.56
|
| Rate for Payer: Cash Price |
$60.85
|
| Rate for Payer: Cigna of CA HMO |
$94.65
|
| Rate for Payer: Cigna of CA PPO |
$94.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$94.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.09
|
| Rate for Payer: EPIC Health Plan Senior |
$54.09
|
| Rate for Payer: Galaxy Health WC |
$114.94
|
| Rate for Payer: Global Benefits Group Commercial |
$81.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$85.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.45
|
| Rate for Payer: Multiplan Commercial |
$108.18
|
| Rate for Payer: Networks By Design Commercial |
$87.89
|
| Rate for Payer: Prime Health Services Commercial |
$114.94
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
OP
|
$135.22
|
|
|
Service Code
|
NDC 5114400160
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$114.94 |
| Rate for Payer: Adventist Health Commercial |
$27.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$88.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$114.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$74.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$101.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.77
|
| Rate for Payer: Cash Price |
$60.85
|
| Rate for Payer: Cigna of CA HMO |
$94.65
|
| Rate for Payer: Cigna of CA PPO |
$94.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$114.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$114.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$114.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$94.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.09
|
| Rate for Payer: EPIC Health Plan Senior |
$54.09
|
| Rate for Payer: Galaxy Health WC |
$114.94
|
| Rate for Payer: Global Benefits Group Commercial |
$81.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$85.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$94.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$94.65
|
| Rate for Payer: Multiplan Commercial |
$108.18
|
| Rate for Payer: Networks By Design Commercial |
$87.89
|
| Rate for Payer: Prime Health Services Commercial |
$114.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$81.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$81.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$67.61
|
| Rate for Payer: United Healthcare All Other HMO |
$67.61
|
| Rate for Payer: United Healthcare HMO Rider |
$67.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$67.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$114.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$114.94
|
| Rate for Payer: Vantage Medical Group Senior |
$114.94
|
|
|
TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 69641
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$300.22 |
| 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 |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,924.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,743.74
|
| Rate for Payer: Blue Shield of California Commercial |
$8,695.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$300.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$339.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL OSSICULAR REPLACEMENT PROSTHESIS [TORP])
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 69633
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$275.20 |
| 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 |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,323.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$275.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$311.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 69631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$275.20 |
| 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 |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,323.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,136.63
|
| Rate for Payer: Blue Shield of California Commercial |
$6,262.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$275.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$311.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,593.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 69436
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$202.66 |
| 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 |
$2,993.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,995.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,716.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,195.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,995.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,292.74
|
| Rate for Payer: EPIC Health Plan Senior |
$2,195.16
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,272.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$202.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,995.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$229.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,793.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,514.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,674.10
|
| Rate for Payer: Multiplan WC |
$2,998.82
|
| Rate for Payer: Prime Health Services WC |
$2,968.22
|
| 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 |
$1,995.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,993.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,195.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1,995.60
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]
|
Facility
|
IP
|
$387.84
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.57 |
| Max. Negotiated Rate |
$329.66 |
| Rate for Payer: Adventist Health Commercial |
$77.57
|
| Rate for Payer: Blue Shield of California Commercial |
$196.63
|
| Rate for Payer: Blue Shield of California Commercial |
$298.25
|
| Rate for Payer: Cash Price |
$174.53
|
| Rate for Payer: Cigna of CA HMO |
$271.49
|
| Rate for Payer: Cigna of CA PPO |
$271.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$271.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$155.14
|
| Rate for Payer: EPIC Health Plan Senior |
$155.14
|
| Rate for Payer: Galaxy Health WC |
$329.66
|
| Rate for Payer: Global Benefits Group Commercial |
$232.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$246.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$228.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.08
|
| Rate for Payer: Multiplan Commercial |
$310.27
|
| Rate for Payer: Networks By Design Commercial |
$193.92
|
| Rate for Payer: Prime Health Services Commercial |
$329.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$145.56
|
| Rate for Payer: United Healthcare All Other HMO |
$141.68
|
| Rate for Payer: United Healthcare HMO Rider |
$138.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$127.02
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [14678]
|
Facility
|
OP
|
$387.84
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.57 |
| Max. Negotiated Rate |
$1,039.35 |
| Rate for Payer: Adventist Health Commercial |
$77.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,039.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$329.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$213.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$290.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$111.82
|
| Rate for Payer: Blue Shield of California Commercial |
$135.58
|
| Rate for Payer: Cash Price |
$174.53
|
| Rate for Payer: Cash Price |
$174.53
|
| Rate for Payer: Cigna of CA HMO |
$271.49
|
| Rate for Payer: Cigna of CA PPO |
$271.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$329.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$329.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$329.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$271.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$155.14
|
| Rate for Payer: EPIC Health Plan Senior |
$155.14
|
| Rate for Payer: Galaxy Health WC |
$329.66
|
| Rate for Payer: Global Benefits Group Commercial |
$232.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$239.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$246.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$270.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$228.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$271.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$271.49
|
| Rate for Payer: Multiplan Commercial |
$310.27
|
| Rate for Payer: Networks By Design Commercial |
$193.92
|
| Rate for Payer: Prime Health Services Commercial |
$329.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$232.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$232.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$145.56
|
| Rate for Payer: United Healthcare All Other HMO |
$141.68
|
| Rate for Payer: United Healthcare HMO Rider |
$138.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$127.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$329.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$329.66
|
| Rate for Payer: Vantage Medical Group Senior |
$329.66
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC
|
Facility
|
IP
|
$178,020.86
|
|
|
Service Code
|
MSDRG 278
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$178,020.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$168,744.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$178,020.86
|
| Rate for Payer: EPIC Health Plan Senior |
$118,680.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$107,891.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$151,048.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$144,574.52
|
| 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
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC
|
Facility
|
IP
|
$143,244.55
|
|
|
Service Code
|
MSDRG 279
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$143,244.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$109,331.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$143,244.55
|
| Rate for Payer: EPIC Health Plan Senior |
$95,496.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$86,814.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$121,540.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$116,331.94
|
| 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
|
|
|
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM
|
Facility
|
IP
|
$132,065.32
|
|
|
Service Code
|
MSDRG 173
|
| Min. Negotiated Rate |
$80,039.59 |
| Max. Negotiated Rate |
$132,065.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$90,232.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$132,065.32
|
| Rate for Payer: EPIC Health Plan Senior |
$88,043.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$80,039.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$112,055.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$107,253.05
|
|
|
UNCLASSIFIED DRUGS
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT J3490
|
|
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
|
|
