|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
|
IP
|
$18,588.16
|
|
|
Service Code
|
APR-DRG 4461
|
| Min. Negotiated Rate |
$14,846.07 |
| Max. Negotiated Rate |
$18,588.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,846.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,588.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16,631.51
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
|
IP
|
$36,289.87
|
|
|
Service Code
|
APR-DRG 4463
|
| Min. Negotiated Rate |
$28,984.14 |
| Max. Negotiated Rate |
$36,289.87 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28,984.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$36,289.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32,469.88
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
|
IP
|
$24,458.81
|
|
|
Service Code
|
APR-DRG 4462
|
| Min. Negotiated Rate |
$19,534.87 |
| Max. Negotiated Rate |
$24,458.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,534.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,458.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21,884.20
|
|
|
URETHRAL PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$111,101.58
|
|
|
Service Code
|
MSDRG 671
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$111,101.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54,417.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$111,101.58
|
| Rate for Payer: EPIC Health Plan Senior |
$74,067.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,334.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94,268.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$90,227.95
|
| 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
|
|
|
URETHRAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$98,405.16
|
|
|
Service Code
|
MSDRG 672
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$98,405.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,726.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$98,405.16
|
| Rate for Payer: EPIC Health Plan Senior |
$65,603.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,639.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83,495.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79,916.92
|
| 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
|
|
|
URETHRAL STRICTURE
|
Facility
|
IP
|
$98,375.00
|
|
|
Service Code
|
MSDRG 697
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$98,375.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32,674.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$98,375.00
|
| Rate for Payer: EPIC Health Plan Senior |
$65,583.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59,621.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83,469.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79,892.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); LESS THAN 3 CM
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 54308
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,105.83 |
| 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 |
$10,344.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,585.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,896.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,104.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,942.61
|
| Rate for Payer: Blue Shield of California Commercial |
$4,454.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,344.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,585.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,896.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,378.68
|
| Rate for Payer: EPIC Health Plan Senior |
$7,585.79
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,309.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,105.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,896.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,250.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,654.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,689.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,240.87
|
| Rate for Payer: Multiplan WC |
$10,291.67
|
| Rate for Payer: Prime Health Services WC |
$10,186.65
|
| 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 |
$6,896.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,344.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,585.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6,896.17
|
|
|
URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION) WITH FREE SKIN GRAFT OBTAINED FROM SITE OTHER THAN GENITALIA
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 54316
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,275.32 |
| 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 |
$18,263.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13,393.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12,175.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,104.00
|
| 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 |
$18,263.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$13,393.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12,175.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,089.49
|
| Rate for Payer: EPIC Health Plan Senior |
$13,393.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$19,967.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,275.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,175.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,442.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,045.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15,341.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16,315.10
|
| Rate for Payer: Multiplan WC |
$18,720.61
|
| Rate for Payer: Prime Health Services WC |
$18,529.58
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$12,175.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18,263.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13,393.00
|
| Rate for Payer: Vantage Medical Group Senior |
$12,175.45
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
|
IP
|
$12,122.00
|
|
|
Service Code
|
APR-DRG 4651
|
| Min. Negotiated Rate |
$9,681.65 |
| Max. Negotiated Rate |
$12,122.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,681.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,122.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,846.00
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
|
IP
|
$52,259.16
|
|
|
Service Code
|
APR-DRG 4654
|
| Min. Negotiated Rate |
$41,738.56 |
| Max. Negotiated Rate |
$52,259.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41,738.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52,259.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46,758.19
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
|
IP
|
$15,374.12
|
|
|
Service Code
|
APR-DRG 4652
|
| Min. Negotiated Rate |
$12,279.06 |
| Max. Negotiated Rate |
$15,374.12 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,279.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,374.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13,755.79
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
|
IP
|
$22,642.41
|
|
|
Service Code
|
APR-DRG 4653
|
| Min. Negotiated Rate |
$18,084.14 |
| Max. Negotiated Rate |
$22,642.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,084.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22,642.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,259.00
|
|
|
URINARY STONES WITH MCC
|
Facility
|
IP
|
$103,107.54
|
|
|
Service Code
|
MSDRG 693
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$103,107.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$40,759.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$103,107.54
|
| Rate for Payer: EPIC Health Plan Senior |
$68,738.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$62,489.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$87,485.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$83,735.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
URINARY STONES WITHOUT MCC
|
Facility
|
IP
|
$93,120.74
|
|
|
Service Code
|
MSDRG 694
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$93,120.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,698.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$93,120.74
|
| Rate for Payer: EPIC Health Plan Senior |
$62,080.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,436.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,011.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75,625.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 6068752711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.70
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 6068752711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$2.13
|
| Rate for Payer: Blue Shield of California Commercial |
$3.23
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$3.95
|
|
|
Service Code
|
NDC 0904689004
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cigna of CA HMO |
$2.77
|
| Rate for Payer: Cigna of CA PPO |
$2.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.36
|
| Rate for Payer: Global Benefits Group Commercial |
$2.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$3.16
|
| Rate for Payer: Networks By Design Commercial |
$2.57
|
| Rate for Payer: Prime Health Services Commercial |
$3.36
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 6068752721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.70
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 7071011271
|
| 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 |
$1.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.09
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| 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 |
$1.19
|
| 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 |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO |
$0.85
|
| Rate for Payer: United Healthcare HMO Rider |
$0.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.85
|
| 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
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 6068752721
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$2.13
|
| Rate for Payer: Blue Shield of California Commercial |
$3.23
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Senior |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Commercial |
$3.36
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
IP
|
$1.70
|
|
|
Service Code
|
NDC 7071011271
|
| 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: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.19
|
| 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 |
$1.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.36
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.45
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
|
OP
|
$3.95
|
|
|
Service Code
|
NDC 0904689004
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Adventist Health Commercial |
$0.79
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.53
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cigna of CA HMO |
$2.77
|
| Rate for Payer: Cigna of CA PPO |
$2.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.58
|
| Rate for Payer: EPIC Health Plan Senior |
$1.58
|
| Rate for Payer: Galaxy Health WC |
$3.36
|
| Rate for Payer: Global Benefits Group Commercial |
$2.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.77
|
| Rate for Payer: Multiplan Commercial |
$3.16
|
| Rate for Payer: Networks By Design Commercial |
$2.57
|
| Rate for Payer: Prime Health Services Commercial |
$3.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.98
|
| Rate for Payer: United Healthcare All Other HMO |
$1.98
|
| Rate for Payer: United Healthcare HMO Rider |
$1.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.36
|
| Rate for Payer: Vantage Medical Group Senior |
$3.36
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 5965142101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.61
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO |
$0.67
|
| Rate for Payer: Cigna of CA PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Senior |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.81
|
| Rate for Payer: Global Benefits Group Commercial |
$0.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: Networks By Design Commercial |
$0.62
|
| Rate for Payer: Prime Health Services Commercial |
$0.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO |
$0.48
|
| Rate for Payer: United Healthcare HMO Rider |
$0.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Vantage Medical Group Senior |
$0.81
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 7071014831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 6068710011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$3.62
|
| Rate for Payer: Blue Shield of California Commercial |
$5.49
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Senior |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.71
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
|
