|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
1715158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$71,458.03
|
|
|
Service Code
|
APR-DRG 1652
|
| Min. Negotiated Rate |
$54,815.83 |
| Max. Negotiated Rate |
$71,458.03 |
| Rate for Payer: IEHP Medi-Cal |
$54,815.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71,458.03
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$116,330.10
|
|
|
Service Code
|
APR-DRG 1654
|
| Min. Negotiated Rate |
$89,237.43 |
| Max. Negotiated Rate |
$116,330.10 |
| Rate for Payer: IEHP Medi-Cal |
$89,237.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$116,330.10
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$58,682.01
|
|
|
Service Code
|
APR-DRG 1651
|
| Min. Negotiated Rate |
$45,015.28 |
| Max. Negotiated Rate |
$58,682.01 |
| Rate for Payer: IEHP Medi-Cal |
$45,015.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58,682.01
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$85,917.05
|
|
|
Service Code
|
APR-DRG 1653
|
| Min. Negotiated Rate |
$65,907.42 |
| Max. Negotiated Rate |
$85,917.05 |
| Rate for Payer: IEHP Medi-Cal |
$65,907.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85,917.05
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$60,150.45
|
|
|
Service Code
|
APR-DRG 1662
|
| Min. Negotiated Rate |
$46,141.72 |
| Max. Negotiated Rate |
$60,150.45 |
| Rate for Payer: IEHP Medi-Cal |
$46,141.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60,150.45
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$104,861.15
|
|
|
Service Code
|
APR-DRG 1664
|
| Min. Negotiated Rate |
$80,439.54 |
| Max. Negotiated Rate |
$104,861.15 |
| Rate for Payer: IEHP Medi-Cal |
$80,439.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104,861.15
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$54,019.58
|
|
|
Service Code
|
APR-DRG 1661
|
| Min. Negotiated Rate |
$41,438.71 |
| Max. Negotiated Rate |
$54,019.58 |
| Rate for Payer: IEHP Medi-Cal |
$41,438.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54,019.58
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$71,431.43
|
|
|
Service Code
|
APR-DRG 1663
|
| Min. Negotiated Rate |
$54,795.43 |
| Max. Negotiated Rate |
$71,431.43 |
| Rate for Payer: IEHP Medi-Cal |
$54,795.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71,431.43
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041F4JJ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 06S83ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 05100JY
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 021K4KP
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 06S24ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041D4A8
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 02Q10ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041F0ZP
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041F49F
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 02PA08Z
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02730D6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041H4JF
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041C4JD
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Coronary Surgery
|
Facility
IP
|
$10,022.00
|
|
|
Service Code
|
ICD 041E0AF
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$10,022.00 |
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
