|
DENOSUMAB-BMWO 60 MG/ML SUBCUTANEOUS SYRINGE [246286]
|
Facility
|
IP
|
$2,137.99
|
|
|
Service Code
|
HCPCS Q5157
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.60 |
| Max. Negotiated Rate |
$1,817.29 |
| Rate for Payer: EPIC Health Plan Senior |
$855.20
|
| Rate for Payer: Galaxy Health WC |
$1,817.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$855.20
|
| Rate for Payer: Adventist Health Commercial |
$427.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,083.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1,644.11
|
| Rate for Payer: Cash Price |
$962.10
|
| Rate for Payer: Cigna of CA HMO |
$1,496.59
|
| Rate for Payer: Cigna of CA PPO |
$1,496.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,496.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1,282.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,357.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,261.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$513.12
|
| Rate for Payer: Multiplan Commercial |
$1,710.39
|
| Rate for Payer: Networks By Design Commercial |
$1,068.99
|
| Rate for Payer: Prime Health Services Commercial |
$1,817.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$802.39
|
| Rate for Payer: United Healthcare All Other HMO |
$781.01
|
| Rate for Payer: United Healthcare HMO Rider |
$764.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$700.19
|
|
|
DENOSUMAB-DSSB 60 MG/ML SUBCUTANEOUS SYRINGE [247538]
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
HCPCS Q5159
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$994.50 |
| Rate for Payer: Adventist Health Commercial |
$234.00
|
| Rate for Payer: Blue Shield of California Commercial |
$593.19
|
| Rate for Payer: Blue Shield of California Commercial |
$899.73
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna of CA HMO |
$819.00
|
| Rate for Payer: Cigna of CA PPO |
$819.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$819.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$468.00
|
| Rate for Payer: EPIC Health Plan Senior |
$468.00
|
| Rate for Payer: Galaxy Health WC |
$994.50
|
| Rate for Payer: Global Benefits Group Commercial |
$702.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$742.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$690.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$280.80
|
| Rate for Payer: Multiplan Commercial |
$936.00
|
| Rate for Payer: Networks By Design Commercial |
$585.00
|
| Rate for Payer: Prime Health Services Commercial |
$994.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$439.10
|
| Rate for Payer: United Healthcare All Other HMO |
$427.40
|
| Rate for Payer: United Healthcare HMO Rider |
$418.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$383.18
|
|
|
DENOSUMAB-DSSB 60 MG/ML SUBCUTANEOUS SYRINGE [247538]
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
HCPCS Q5159
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.56 |
| Max. Negotiated Rate |
$994.50 |
| Rate for Payer: Adventist Health Commercial |
$234.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$767.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$994.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$643.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$877.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$41.56
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cash Price |
$526.50
|
| Rate for Payer: Cigna of CA HMO |
$819.00
|
| Rate for Payer: Cigna of CA PPO |
$819.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$994.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$994.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$994.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$819.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$468.00
|
| Rate for Payer: EPIC Health Plan Senior |
$468.00
|
| Rate for Payer: Galaxy Health WC |
$994.50
|
| Rate for Payer: Global Benefits Group Commercial |
$702.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$742.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$424.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$690.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$280.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$819.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$819.00
|
| Rate for Payer: Multiplan Commercial |
$936.00
|
| Rate for Payer: Networks By Design Commercial |
$585.00
|
| Rate for Payer: Prime Health Services Commercial |
$994.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$702.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$702.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$439.10
|
| Rate for Payer: United Healthcare All Other HMO |
$427.40
|
| Rate for Payer: United Healthcare HMO Rider |
$418.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$383.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$994.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$994.50
|
| Rate for Payer: Vantage Medical Group Senior |
$994.50
|
|
|
DENOSUMAB-NXXP 60 MG/ML SUBCUTANEOUS SYRINGE [247605]
|
Facility
|
OP
|
$1,012.80
|
|
|
Service Code
|
HCPCS Q5162
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$860.88 |
| Rate for Payer: Adventist Health Commercial |
$202.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$664.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$649.91
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cigna of CA HMO |
$708.96
|
| Rate for Payer: Cigna of CA PPO |
$708.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.66
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$708.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.84
|
| Rate for Payer: EPIC Health Plan Senior |
$17.23
|
| Rate for Payer: Galaxy Health WC |
$860.88
|
| Rate for Payer: Global Benefits Group Commercial |
$607.68
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$25.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$643.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$35.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.98
|
| Rate for Payer: Multiplan Commercial |
$810.24
|
| Rate for Payer: Networks By Design Commercial |
$506.40
|
| Rate for Payer: Prime Health Services Commercial |
$860.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$607.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$607.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$380.10
|
| Rate for Payer: United Healthcare All Other HMO |
$369.98
|
| Rate for Payer: United Healthcare HMO Rider |
$361.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$331.69
|
| Rate for Payer: Upland Medical Group Pediatric |
$15.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.23
|
| Rate for Payer: Vantage Medical Group Senior |
$15.66
|
|
|
DENOSUMAB-NXXP 60 MG/ML SUBCUTANEOUS SYRINGE [247605]
|
Facility
|
IP
|
$1,012.80
|
|
|
Service Code
|
HCPCS Q5162
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.56 |
| Max. Negotiated Rate |
$860.88 |
| Rate for Payer: Adventist Health Commercial |
$202.56
|
| Rate for Payer: Blue Shield of California Commercial |
$513.49
|
| Rate for Payer: Blue Shield of California Commercial |
$778.84
|
| Rate for Payer: Cash Price |
$455.76
|
| Rate for Payer: Cigna of CA HMO |
$708.96
|
| Rate for Payer: Cigna of CA PPO |
$708.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$708.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$405.12
|
| Rate for Payer: EPIC Health Plan Senior |
$405.12
|
| Rate for Payer: Galaxy Health WC |
$860.88
|
| Rate for Payer: Global Benefits Group Commercial |
$607.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$643.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$597.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.07
|
| Rate for Payer: Multiplan Commercial |
$810.24
|
| Rate for Payer: Networks By Design Commercial |
$506.40
|
| Rate for Payer: Prime Health Services Commercial |
$860.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$380.10
|
| Rate for Payer: United Healthcare All Other HMO |
$369.98
|
| Rate for Payer: United Healthcare HMO Rider |
$361.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$331.69
|
|
|
DENOSUMAB-QBDE 60 MG/ML SUBCUTANEOUS SYRINGE [248500]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
HCPCS Q5167
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$314.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$308.02
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$336.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.53
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$304.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$174.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$288.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$288.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$180.14
|
| Rate for Payer: United Healthcare All Other HMO |
$175.34
|
| Rate for Payer: United Healthcare HMO Rider |
$171.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$157.20
|
| Rate for Payer: Upland Medical Group Pediatric |
$4.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.53
|
| Rate for Payer: Vantage Medical Group Senior |
$4.12
|
|
|
DENOSUMAB-QBDE 60 MG/ML SUBCUTANEOUS SYRINGE [248500]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS Q5167
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.00 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Adventist Health Commercial |
$96.00
|
| Rate for Payer: Blue Shield of California Commercial |
$243.36
|
| Rate for Payer: Blue Shield of California Commercial |
$369.12
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$336.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: EPIC Health Plan Senior |
$192.00
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$304.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$283.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$180.14
|
| Rate for Payer: United Healthcare All Other HMO |
$175.34
|
| Rate for Payer: United Healthcare HMO Rider |
$171.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$157.20
|
|
|
DENTAL AND ORAL DISEASES WITH CC
|
Facility
|
IP
|
$95,393.84
|
|
|
Service Code
|
MSDRG 158
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$95,393.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,581.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$95,393.84
|
| Rate for Payer: EPIC Health Plan Senior |
$63,595.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,814.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$80,940.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$77,471.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
DENTAL AND ORAL DISEASES WITH MCC
|
Facility
|
IP
|
$109,713.93
|
|
|
Service Code
|
MSDRG 157
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$109,713.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$52,046.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$109,713.93
|
| Rate for Payer: EPIC Health Plan Senior |
$73,142.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$66,493.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$93,090.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89,101.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$91,821.84
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$91,821.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,478.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$91,821.84
|
| Rate for Payer: EPIC Health Plan Senior |
$61,214.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55,649.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$77,909.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74,570.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$8,437.54
|
|
|
Service Code
|
APR-DRG 1141
|
| Min. Negotiated Rate |
$6,738.93 |
| Max. Negotiated Rate |
$8,437.54 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,738.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,437.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7,549.38
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$17,766.98
|
|
|
Service Code
|
APR-DRG 1143
|
| Min. Negotiated Rate |
$14,190.20 |
| Max. Negotiated Rate |
$17,766.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,190.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,766.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15,896.77
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$52,586.98
|
|
|
Service Code
|
APR-DRG 1144
|
| Min. Negotiated Rate |
$42,000.39 |
| Max. Negotiated Rate |
$52,586.98 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$42,000.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52,586.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47,051.51
|
|
|
DENTAL DISEASES AND DISORDERS
|
Facility
|
IP
|
$11,814.73
|
|
|
Service Code
|
APR-DRG 1142
|
| Min. Negotiated Rate |
$9,436.24 |
| Max. Negotiated Rate |
$11,814.73 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,436.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11,814.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,571.08
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$13,446.74
|
|
|
Service Code
|
APR-DRG 7513
|
| Min. Negotiated Rate |
$10,739.70 |
| Max. Negotiated Rate |
$13,446.74 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,739.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13,446.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12,031.29
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$28,301.39
|
|
|
Service Code
|
APR-DRG 7514
|
| Min. Negotiated Rate |
$22,603.88 |
| Max. Negotiated Rate |
$28,301.39 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22,603.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28,301.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25,322.30
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$7,347.76
|
|
|
Service Code
|
APR-DRG 7512
|
| Min. Negotiated Rate |
$5,868.54 |
| Max. Negotiated Rate |
$7,347.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,868.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,347.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,574.31
|
|
|
DEPRESSIVE DISORDERS
|
Facility
|
IP
|
$5,776.70
|
|
|
Service Code
|
APR-DRG 7511
|
| Min. Negotiated Rate |
$4,613.76 |
| Max. Negotiated Rate |
$5,776.70 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,613.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,776.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,168.63
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$95,945.73
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$95,945.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28,524.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$95,945.73
|
| Rate for Payer: EPIC Health Plan Senior |
$63,963.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58,148.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81,408.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$77,919.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 5074211301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 4596334202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.67
|
| Rate for Payer: United Healthcare All Other HMO |
$0.67
|
| Rate for Payer: United Healthcare HMO Rider |
$0.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 5074211301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 4596334202
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO |
$0.94
|
| Rate for Payer: Cigna of CA PPO |
$0.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Senior |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.87
|
| Rate for Payer: Prime Health Services Commercial |
$1.14
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 6800157400
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 6050502571
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.62
|
| Rate for Payer: Cigna of CA PPO |
$0.62
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Senior |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.75
|
| Rate for Payer: Global Benefits Group Commercial |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.75
|
|
