|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 4280650301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 6068710001
|
| 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: Aetna of CA HMO/PPO |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.58
|
| 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: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.07
|
| 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 Medi-Cal |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.57
|
| Rate for Payer: United Healthcare All Other HMO |
$3.57
|
| Rate for Payer: United Healthcare HMO Rider |
$3.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
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
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$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: Aetna of CA HMO/PPO |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.58
|
| 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: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.07
|
| 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 Medi-Cal |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.57
|
| Rate for Payer: United Healthcare All Other HMO |
$3.57
|
| Rate for Payer: United Healthcare HMO Rider |
$3.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| 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: 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 Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| 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
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527132601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 0527132601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| 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: 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 Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| 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
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
OP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$87.31 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$80.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31.46
|
| Rate for Payer: Blue Shield of California Commercial |
$18.69
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cigna of CA HMO |
$71.90
|
| Rate for Payer: Cigna of CA PPO |
$71.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.74
|
| Rate for Payer: EPIC Health Plan Senior |
$12.50
|
| Rate for Payer: Galaxy Health WC |
$87.31
|
| Rate for Payer: Global Benefits Group Commercial |
$61.63
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$65.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.22
|
| Rate for Payer: Multiplan Commercial |
$82.18
|
| Rate for Payer: Networks By Design Commercial |
$51.36
|
| Rate for Payer: Prime Health Services Commercial |
$87.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.55
|
| Rate for Payer: United Healthcare All Other HMO |
$37.52
|
| Rate for Payer: United Healthcare HMO Rider |
$36.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.64
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Vantage Medical Group Senior |
$12.50
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
IP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$87.31 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Blue Shield of California Commercial |
$52.08
|
| Rate for Payer: Blue Shield of California Commercial |
$78.99
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cigna of CA HMO |
$71.90
|
| Rate for Payer: Cigna of CA PPO |
$71.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.09
|
| Rate for Payer: EPIC Health Plan Senior |
$41.09
|
| Rate for Payer: Galaxy Health WC |
$87.31
|
| Rate for Payer: Global Benefits Group Commercial |
$61.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$65.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.65
|
| Rate for Payer: Multiplan Commercial |
$82.18
|
| Rate for Payer: Networks By Design Commercial |
$51.36
|
| Rate for Payer: Prime Health Services Commercial |
$87.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.55
|
| Rate for Payer: United Healthcare All Other HMO |
$37.52
|
| Rate for Payer: United Healthcare HMO Rider |
$36.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.64
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
IP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,346.17 |
| Max. Negotiated Rate |
$31,221.21 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Blue Shield of California Commercial |
$18,622.54
|
| Rate for Payer: Blue Shield of California Commercial |
$28,246.02
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cigna of CA HMO |
$25,711.59
|
| Rate for Payer: Cigna of CA PPO |
$25,711.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,692.34
|
| Rate for Payer: EPIC Health Plan Senior |
$14,692.34
|
| Rate for Payer: Galaxy Health WC |
$31,221.21
|
| Rate for Payer: Global Benefits Group Commercial |
$22,038.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,324.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,671.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,815.40
|
| Rate for Payer: Multiplan Commercial |
$29,384.67
|
| Rate for Payer: Networks By Design Commercial |
$18,365.42
|
| Rate for Payer: Prime Health Services Commercial |
$31,221.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,785.08
|
| Rate for Payer: United Healthcare All Other HMO |
$13,417.78
|
| Rate for Payer: United Healthcare HMO Rider |
$13,127.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,029.35
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
OP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$277.70 |
| Max. Negotiated Rate |
$31,221.21 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,008.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20,201.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27,548.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$277.70
|
| Rate for Payer: Blue Shield of California Commercial |
$371.24
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cigna of CA HMO |
$25,711.59
|
| Rate for Payer: Cigna of CA PPO |
$25,711.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$31,221.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31,221.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,692.34
|
| Rate for Payer: EPIC Health Plan Senior |
$14,692.34
|
| Rate for Payer: Galaxy Health WC |
$31,221.21
|
| Rate for Payer: Global Benefits Group Commercial |
$22,038.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$537.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,324.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$607.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,671.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,815.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25,711.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25,711.59
|
| Rate for Payer: Multiplan Commercial |
$29,384.67
|
| Rate for Payer: Networks By Design Commercial |
$18,365.42
|
| Rate for Payer: Prime Health Services Commercial |
$31,221.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22,038.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22,038.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,785.08
|
| Rate for Payer: United Healthcare All Other HMO |
$13,417.78
|
| Rate for Payer: United Healthcare HMO Rider |
$13,127.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,029.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Senior |
$31,221.21
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$104,169.38
|
|
|
Service Code
|
APR-DRG 5194
|
| Min. Negotiated Rate |
$83,198.44 |
| Max. Negotiated Rate |
$104,169.38 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83,198.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$104,169.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$93,204.18
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$20,070.10
|
|
|
Service Code
|
APR-DRG 5191
|
| Min. Negotiated Rate |
$16,029.67 |
| Max. Negotiated Rate |
$20,070.10 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,029.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,070.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17,957.46
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$43,615.28
|
|
|
Service Code
|
APR-DRG 5193
|
| Min. Negotiated Rate |
$34,834.83 |
| Max. Negotiated Rate |
$43,615.28 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34,834.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43,615.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39,024.20
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$25,519.28
|
|
|
Service Code
|
APR-DRG 5192
|
| Min. Negotiated Rate |
$20,381.85 |
| Max. Negotiated Rate |
$25,519.28 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,381.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25,519.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22,833.04
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$26,604.22
|
|
|
Service Code
|
APR-DRG 5132
|
| Min. Negotiated Rate |
$21,248.37 |
| Max. Negotiated Rate |
$26,604.22 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,248.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26,604.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23,803.77
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$41,894.05
|
|
|
Service Code
|
APR-DRG 5133
|
| Min. Negotiated Rate |
$33,460.12 |
| Max. Negotiated Rate |
$41,894.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,460.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$41,894.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37,484.15
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$21,535.72
|
|
|
Service Code
|
APR-DRG 5131
|
| Min. Negotiated Rate |
$17,200.24 |
| Max. Negotiated Rate |
$21,535.72 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,200.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21,535.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19,268.80
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$101,797.15
|
|
|
Service Code
|
APR-DRG 5134
|
| Min. Negotiated Rate |
$81,303.78 |
| Max. Negotiated Rate |
$101,797.15 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81,303.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$101,797.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$91,081.66
|
|
