|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Blue Shield of California Commercial |
$451.19
|
| Rate for Payer: Blue Shield of California Commercial |
$684.35
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.58
|
| Rate for Payer: Multiplan Commercial |
$711.94
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
|
|
BOSUTINIB 400 MG TABLET [220449]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069019301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$583.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$571.06
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$323.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$622.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$711.94
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$533.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$533.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$444.96
|
| Rate for Payer: United Healthcare All Other HMO |
$444.96
|
| Rate for Payer: United Healthcare HMO Rider |
$444.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
IP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Blue Shield of California Commercial |
$451.19
|
| Rate for Payer: Blue Shield of California Commercial |
$684.35
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.58
|
| Rate for Payer: Multiplan Commercial |
$711.94
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
|
|
BOSUTINIB 500 MG TABLET [197247]
|
Facility
|
OP
|
$889.92
|
|
|
Service Code
|
NDC 0069013601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.98 |
| Max. Negotiated Rate |
$756.43 |
| Rate for Payer: Adventist Health Commercial |
$177.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$583.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$489.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$667.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$571.06
|
| Rate for Payer: Cash Price |
$400.46
|
| Rate for Payer: Cigna of CA HMO |
$622.94
|
| Rate for Payer: Cigna of CA PPO |
$622.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$756.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$756.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$622.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$355.97
|
| Rate for Payer: EPIC Health Plan Senior |
$355.97
|
| Rate for Payer: Galaxy Health WC |
$756.43
|
| Rate for Payer: Global Benefits Group Commercial |
$533.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$565.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$323.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$525.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$622.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$622.94
|
| Rate for Payer: Multiplan Commercial |
$711.94
|
| Rate for Payer: Networks By Design Commercial |
$578.45
|
| Rate for Payer: Prime Health Services Commercial |
$756.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$533.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$533.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$444.96
|
| Rate for Payer: United Healthcare All Other HMO |
$444.96
|
| Rate for Payer: United Healthcare HMO Rider |
$444.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$444.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$756.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.43
|
| Rate for Payer: Vantage Medical Group Senior |
$756.43
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
OP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54,360.00 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$178,273.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$203,850.00
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$231,030.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$231,030.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190,260.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Senior |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172,593.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160,362.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65,232.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$190,260.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$190,260.00
|
| Rate for Payer: Multiplan Commercial |
$217,440.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163,080.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163,080.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$102,006.54
|
| Rate for Payer: United Healthcare All Other HMO |
$99,288.54
|
| Rate for Payer: United Healthcare HMO Rider |
$97,141.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$89,014.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
IP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54,360.00 |
| Max. Negotiated Rate |
$231,030.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Blue Shield of California Commercial |
$137,802.60
|
| Rate for Payer: Blue Shield of California Commercial |
$209,014.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190,260.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Senior |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172,593.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160,362.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65,232.00
|
| Rate for Payer: Multiplan Commercial |
$217,440.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$102,006.54
|
| Rate for Payer: United Healthcare All Other HMO |
$99,288.54
|
| Rate for Payer: United Healthcare HMO Rider |
$97,141.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$89,014.50
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$36,541.94
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$29,185.47 |
| Max. Negotiated Rate |
$36,541.94 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$29,185.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$36,541.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32,695.42
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$8,113.97
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$6,480.50 |
| Max. Negotiated Rate |
$8,113.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,480.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,113.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,259.87
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$19,357.67
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$15,460.67 |
| Max. Negotiated Rate |
$19,357.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,460.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19,357.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17,320.03
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$11,986.04
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$9,573.06 |
| Max. Negotiated Rate |
$11,986.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,573.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,986.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,724.35
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$12,464.61
|
|
|
Service Code
|
APR-DRG 0561
|
| Min. Negotiated Rate |
$9,955.29 |
| Max. Negotiated Rate |
$12,464.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,955.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,464.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,152.54
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$26,862.54
|
|
|
Service Code
|
APR-DRG 0563
|
| Min. Negotiated Rate |
$21,454.69 |
| Max. Negotiated Rate |
$26,862.54 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,454.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26,862.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24,034.91
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$59,837.56
|
|
|
Service Code
|
APR-DRG 0564
|
| Min. Negotiated Rate |
$47,791.31 |
| Max. Negotiated Rate |
$59,837.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$47,791.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59,837.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$53,538.86
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$17,250.33
|
|
|
Service Code
|
APR-DRG 0562
|
| Min. Negotiated Rate |
$13,777.56 |
| Max. Negotiated Rate |
$17,250.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,777.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,250.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15,434.50
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$117,235.96
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$117,235.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$64,897.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$117,235.96
|
| Rate for Payer: EPIC Health Plan Senior |
$78,157.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$71,052.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$99,472.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95,209.81
|
| 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
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$113,481.16
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$113,481.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58,482.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$113,481.16
|
| Rate for Payer: EPIC Health Plan Senior |
$75,654.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$68,776.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$96,287.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$92,160.46
|
| 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
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$42,524.89
|
|
|
Service Code
|
APR-DRG 3632
|
| Min. Negotiated Rate |
$33,963.96 |
| Max. Negotiated Rate |
$42,524.89 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,963.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42,524.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$38,048.58
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$58,391.16
|
|
|
Service Code
|
APR-DRG 3633
|
| Min. Negotiated Rate |
$46,636.10 |
| Max. Negotiated Rate |
$58,391.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46,636.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58,391.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52,244.72
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$24,292.94
|
|
|
Service Code
|
APR-DRG 3631
|
| Min. Negotiated Rate |
$19,402.39 |
| Max. Negotiated Rate |
$24,292.94 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,402.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$24,292.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21,735.79
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$90,288.59
|
|
|
Service Code
|
APR-DRG 3634
|
| Min. Negotiated Rate |
$72,112.07 |
| Max. Negotiated Rate |
$90,288.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$72,112.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90,288.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$80,784.53
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$32,312.00
|
|
|
Service Code
|
CPT 19318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,669.99 |
| 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 |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,323.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,508.41
|
| Rate for Payer: Blue Shield of California Commercial |
$3,638.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,091.61
|
| Rate for Payer: EPIC Health Plan Senior |
$9,394.41
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14,006.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,669.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,888.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,956.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,760.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: Prime Health Services WC |
$13,067.80
|
| 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 |
$8,540.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
OP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.96 |
| Max. Negotiated Rate |
$13,957.48 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$490.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$418.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$279.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.96
|
| Rate for Payer: Blue Shield of California Commercial |
$281.81
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cigna of CA HMO |
$11,494.39
|
| Rate for Payer: Cigna of CA PPO |
$11,494.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$349.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$307.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$307.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,494.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$460.70
|
| Rate for Payer: EPIC Health Plan Senior |
$307.13
|
| Rate for Payer: Galaxy Health WC |
$13,957.48
|
| Rate for Payer: Global Benefits Group Commercial |
$9,852.34
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$457.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$279.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$279.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,427.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$510.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$390.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,940.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$351.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$374.14
|
| Rate for Payer: Multiplan Commercial |
$13,136.45
|
| Rate for Payer: Networks By Design Commercial |
$8,210.28
|
| Rate for Payer: Prime Health Services Commercial |
$13,957.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9,852.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9,852.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,162.64
|
| Rate for Payer: United Healthcare All Other HMO |
$5,998.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5,868.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,377.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$279.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$349.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
IP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,284.11 |
| Max. Negotiated Rate |
$13,957.48 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Blue Shield of California Commercial |
$12,627.41
|
| Rate for Payer: Blue Shield of California Commercial |
$8,325.22
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cigna of CA HMO |
$11,494.39
|
| Rate for Payer: Cigna of CA PPO |
$11,494.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,494.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,568.22
|
| Rate for Payer: EPIC Health Plan Senior |
$6,568.22
|
| Rate for Payer: Galaxy Health WC |
$13,957.48
|
| Rate for Payer: Global Benefits Group Commercial |
$9,852.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,427.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,688.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,940.93
|
| Rate for Payer: Multiplan Commercial |
$13,136.45
|
| Rate for Payer: Networks By Design Commercial |
$8,210.28
|
| Rate for Payer: Prime Health Services Commercial |
$13,957.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,162.64
|
| Rate for Payer: United Healthcare All Other HMO |
$5,998.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5,868.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,377.73
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Blue Shield of California Commercial |
$18.66
|
| Rate for Payer: Blue Shield of California Commercial |
$28.30
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.83
|
| Rate for Payer: Multiplan Commercial |
$29.44
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.61
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$29.44
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.40
|
| Rate for Payer: United Healthcare All Other HMO |
$18.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.28
|
| Rate for Payer: Vantage Medical Group Senior |
$31.28
|
|
