|
APR-DRG 41.00: VIRAL ILLNESS
|
Facility
|
IP
|
$16,228.72
|
|
|
Service Code
|
APR-DRG 7233
|
| Min. Negotiated Rate |
$12,961.62 |
| Max. Negotiated Rate |
$16,228.72 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,961.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,228.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14,520.43
|
|
|
APR-DRG 41.00: VIRAL ILLNESS
|
Facility
|
IP
|
$7,623.48
|
|
|
Service Code
|
APR-DRG 7231
|
| Min. Negotiated Rate |
$6,088.76 |
| Max. Negotiated Rate |
$7,623.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,088.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,623.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,821.01
|
|
|
APR-DRG 41.00: VIRAL ILLNESS
|
Facility
|
IP
|
$47,344.03
|
|
|
Service Code
|
APR-DRG 7234
|
| Min. Negotiated Rate |
$37,812.93 |
| Max. Negotiated Rate |
$47,344.03 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37,812.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47,344.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42,360.45
|
|
|
APR-DRG 41.00: VIRAL ILLNESS
|
Facility
|
IP
|
$10,611.54
|
|
|
Service Code
|
APR-DRG 7232
|
| Min. Negotiated Rate |
$8,475.27 |
| Max. Negotiated Rate |
$10,611.54 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,475.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,611.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,494.53
|
|
|
APR-DRG 41.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$64,559.72
|
|
|
Service Code
|
APR-DRG 0514
|
| Min. Negotiated Rate |
$51,562.83 |
| Max. Negotiated Rate |
$64,559.72 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51,562.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64,559.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57,763.96
|
|
|
APR-DRG 41.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$10,045.77
|
|
|
Service Code
|
APR-DRG 0511
|
| Min. Negotiated Rate |
$8,023.40 |
| Max. Negotiated Rate |
$10,045.77 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,023.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,045.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,988.33
|
|
|
APR-DRG 41.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$14,918.91
|
|
|
Service Code
|
APR-DRG 0512
|
| Min. Negotiated Rate |
$11,915.50 |
| Max. Negotiated Rate |
$14,918.91 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,915.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,918.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13,348.50
|
|
|
APR-DRG 41.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$25,221.44
|
|
|
Service Code
|
APR-DRG 0513
|
| Min. Negotiated Rate |
$20,143.96 |
| Max. Negotiated Rate |
$25,221.44 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,143.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25,221.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22,566.55
|
|
|
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]
|
Facility
|
IP
|
$30.30
|
|
|
Service Code
|
HCPCS J0185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$25.75 |
| Rate for Payer: Adventist Health Commercial |
$6.06
|
| Rate for Payer: Blue Shield of California Commercial |
$22.36
|
| Rate for Payer: Blue Shield of California EPN |
$14.73
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna of CA HMO |
$21.21
|
| Rate for Payer: Cigna of CA PPO |
$21.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.12
|
| Rate for Payer: EPIC Health Plan Senior |
$12.12
|
| Rate for Payer: Galaxy Health WC |
$25.75
|
| Rate for Payer: Global Benefits Group Commercial |
$18.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.27
|
| Rate for Payer: Multiplan Commercial |
$24.24
|
| Rate for Payer: Networks By Design Commercial |
$15.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.37
|
| Rate for Payer: United Healthcare All Other HMO |
$11.07
|
| Rate for Payer: United Healthcare HMO Rider |
$10.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.92
|
|
|
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]
|
Facility
|
OP
|
$30.30
|
|
|
Service Code
|
HCPCS J0185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$25.75 |
| Rate for Payer: Adventist Health Commercial |
$6.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.03
|
| Rate for Payer: Blue Shield of California EPN |
$4.03
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna of CA HMO |
$21.21
|
| Rate for Payer: Cigna of CA PPO |
$21.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: EPIC Health Plan Senior |
$1.77
|
| Rate for Payer: Galaxy Health WC |
$25.75
|
| Rate for Payer: Global Benefits Group Commercial |
$18.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$24.24
|
| Rate for Payer: Networks By Design Commercial |
$15.15
|
| Rate for Payer: Prime Health Services Commercial |
$25.75
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.37
|
| Rate for Payer: United Healthcare All Other HMO |
$11.07
|
| Rate for Payer: United Healthcare HMO Rider |
$10.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.92
|
| Rate for Payer: Upland Medical Group Pediatric |
$1.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.95
|
| Rate for Payer: Vantage Medical Group Senior |
$1.95
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.82
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.26
|
| Rate for Payer: Cash Price |
$6.50
|
| Rate for Payer: Cigna of CA HMO |
$8.27
|
| Rate for Payer: Cigna of CA PPO |
$8.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: EPIC Health Plan Senior |
$4.73
|
| Rate for Payer: Galaxy Health WC |
$10.05
|
| Rate for Payer: Global Benefits Group Commercial |
$7.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: Networks By Design Commercial |
$7.68
|
| Rate for Payer: Prime Health Services Commercial |
$10.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.91
|
| Rate for Payer: United Healthcare All Other HMO |
$5.91
|
| Rate for Payer: United Healthcare HMO Rider |
$5.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.05
|
| Rate for Payer: Vantage Medical Group Senior |
$10.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.82
|
|
|
Service Code
|
NDC 63402-911-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$8.72
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$6.50
|
| Rate for Payer: Cigna of CA HMO |
$8.27
|
| Rate for Payer: Cigna of CA PPO |
$8.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: EPIC Health Plan Senior |
$4.73
|
| Rate for Payer: Galaxy Health WC |
$10.05
|
| Rate for Payer: Global Benefits Group Commercial |
$7.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: Networks By Design Commercial |
$7.68
|
| Rate for Payer: Prime Health Services Commercial |
$10.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$12.17
|
|
|
Service Code
|
NDC 27437-060-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.34 |
| Rate for Payer: Networks By Design Commercial |
$7.91
|
| Rate for Payer: Prime Health Services Commercial |
$10.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.08
|
| Rate for Payer: United Healthcare All Other HMO |
$6.08
|
| Rate for Payer: United Healthcare HMO Rider |
$6.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.34
|
| Rate for Payer: Vantage Medical Group Senior |
$10.34
|
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.47
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Cigna of CA HMO |
$8.52
|
| Rate for Payer: Cigna of CA PPO |
$8.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: EPIC Health Plan Senior |
$4.87
|
| Rate for Payer: Galaxy Health WC |
$10.34
|
| Rate for Payer: Global Benefits Group Commercial |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.52
|
| Rate for Payer: Multiplan Commercial |
$9.74
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$12.17
|
|
|
Service Code
|
NDC 27437-060-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.34 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$8.98
|
| Rate for Payer: Blue Shield of California EPN |
$5.91
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Cigna of CA HMO |
$8.52
|
| Rate for Payer: Cigna of CA PPO |
$8.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: EPIC Health Plan Senior |
$4.87
|
| Rate for Payer: Galaxy Health WC |
$10.34
|
| Rate for Payer: Global Benefits Group Commercial |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$9.74
|
| Rate for Payer: Networks By Design Commercial |
$7.91
|
| Rate for Payer: Prime Health Services Commercial |
$10.34
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.87
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Senior |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.82
|
|
|
Service Code
|
NDC 63402-911-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$8.72
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$6.50
|
| Rate for Payer: Cigna of CA HMO |
$8.27
|
| Rate for Payer: Cigna of CA PPO |
$8.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: EPIC Health Plan Senior |
$4.73
|
| Rate for Payer: Galaxy Health WC |
$10.05
|
| Rate for Payer: Global Benefits Group Commercial |
$7.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: Networks By Design Commercial |
$7.68
|
| Rate for Payer: Prime Health Services Commercial |
$10.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 70748-175-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Networks By Design Commercial |
$0.91
|
| Rate for Payer: Prime Health Services Commercial |
$1.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$0.98
|
| Rate for Payer: Cigna of CA PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 69097-168-48
|
| 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 |
$0.92
|
| Rate for Payer: Cash Price |
$0.83
|
| 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: 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 Permanente of CA Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.93
|
| 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
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 62756-277-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$12.17
|
|
|
Service Code
|
NDC 27437-060-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.34 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.47
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Cigna of CA HMO |
$8.52
|
| Rate for Payer: Cigna of CA PPO |
$8.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: EPIC Health Plan Senior |
$4.87
|
| Rate for Payer: Galaxy Health WC |
$10.34
|
| Rate for Payer: Global Benefits Group Commercial |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.52
|
| Rate for Payer: Multiplan Commercial |
$9.74
|
| Rate for Payer: Networks By Design Commercial |
$7.91
|
| Rate for Payer: Prime Health Services Commercial |
$10.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.08
|
| Rate for Payer: United Healthcare All Other HMO |
$6.08
|
| Rate for Payer: United Healthcare HMO Rider |
$6.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.34
|
| Rate for Payer: Vantage Medical Group Senior |
$10.34
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 69097-168-48
|
| 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 |
$1.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$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 Permanente of CA Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.93
|
| 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
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.93
|
| Rate for Payer: United Healthcare All Other HMO |
$1.93
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.36
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$2.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Senior |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0093-5955-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.36
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$2.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Senior |
$1.54
|
| Rate for Payer: Galaxy Health WC |
$3.27
|
| Rate for Payer: Global Benefits Group Commercial |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$3.08
|
| Rate for Payer: Networks By Design Commercial |
$2.50
|
| Rate for Payer: Prime Health Services Commercial |
$3.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.93
|
| Rate for Payer: United Healthcare All Other HMO |
$1.93
|
| Rate for Payer: United Healthcare HMO Rider |
$1.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$12.17
|
|
|
Service Code
|
NDC 27437-060-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.34 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$8.98
|
| Rate for Payer: Blue Shield of California EPN |
$5.91
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Cigna of CA HMO |
$8.52
|
| Rate for Payer: Cigna of CA PPO |
$8.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.87
|
| Rate for Payer: EPIC Health Plan Senior |
$4.87
|
| Rate for Payer: Galaxy Health WC |
$10.34
|
| Rate for Payer: Global Benefits Group Commercial |
$7.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$9.74
|
| Rate for Payer: Networks By Design Commercial |
$7.91
|
| Rate for Payer: Prime Health Services Commercial |
$10.34
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.82
|
|
|
Service Code
|
NDC 63402-911-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Blue Shield of California Commercial |
$8.72
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$6.50
|
| Rate for Payer: Cigna of CA HMO |
$8.27
|
| Rate for Payer: Cigna of CA PPO |
$8.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.73
|
| Rate for Payer: EPIC Health Plan Senior |
$4.73
|
| Rate for Payer: Galaxy Health WC |
$10.05
|
| Rate for Payer: Global Benefits Group Commercial |
$7.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$9.46
|
| Rate for Payer: Networks By Design Commercial |
$7.68
|
| Rate for Payer: Prime Health Services Commercial |
$10.05
|
|
