|
ANTI-INHIBITOR COAGULANT COMPLEX 350 UNIT-650 UNIT INTRAVENOUS SOLN [225932]
|
Facility
IP
|
$2.70
|
|
|
Service Code
|
CPT J7198
|
| Hospital Charge Code |
ERX225932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$1.89
|
| Rate for Payer: Cigna of CA PPO |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.08
|
| Rate for Payer: Galaxy Health WC |
$2.30
|
| Rate for Payer: Global Benefits Group Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Networks By Design Commercial |
$1.35
|
| Rate for Payer: Prime Health Services Commercial |
$2.30
|
|
|
ANTI-INHIBITOR COAGULANT COMPLEX 700 UNIT-1,300 UNIT INTRAVENOUS SOLN [225933]
|
Facility
OP
|
$3.05
|
|
|
Service Code
|
NDC 64193-424-02
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.82
|
| Rate for Payer: BCBS Transplant Transplant |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: Dignity Health Media |
$2.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$2.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.59
|
| Rate for Payer: Vantage Medical Group Senior |
$2.59
|
|
|
ANTI-INHIBITOR COAGULANT COMPLEX 700 UNIT-1,300 UNIT INTRAVENOUS SOLN [225933]
|
Facility
IP
|
$3.05
|
|
|
Service Code
|
NDC 64193-424-02
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Blue Shield of California Commercial |
$2.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$2.59
|
|
|
ANTI-INHIBITOR COAGULANT COMPLX 1,750 UNIT-3,250 UNIT INTRAVENOUS SOLN [117944]
|
Facility
IP
|
$3.05
|
|
|
Service Code
|
CPT J7198
|
| Hospital Charge Code |
ERX117944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Blue Shield of California Commercial |
$2.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$2.59
|
|
|
ANTI-INHIBITOR COAGULANT COMPLX 1,750 UNIT-3,250 UNIT INTRAVENOUS SOLN [117944]
|
Facility
OP
|
$3.05
|
|
|
Service Code
|
CPT J7198
|
| Hospital Charge Code |
ERX117944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$14.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.49
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.76
|
| Rate for Payer: BCBS Transplant Transplant |
$1.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2.25
|
| Rate for Payer: Blue Shield of California EPN |
$2.70
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.40
|
| Rate for Payer: Dignity Health Media |
$2.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.06
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.27
|
| Rate for Payer: Galaxy Health WC |
$2.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$3.72
|
| Rate for Payer: IEHP Medi-Cal |
$3.67
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3.67
|
| Rate for Payer: IEHP Medicare Advantage |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.04
|
| Rate for Payer: Multiplan Commercial |
$2.44
|
| Rate for Payer: Networks By Design Commercial |
$1.52
|
| Rate for Payer: Prime Health Services Commercial |
$2.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO |
$1.52
|
| Rate for Payer: United Healthcare HMO Rider |
$1.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.49
|
| Rate for Payer: Vantage Medical Group Senior |
$2.27
|
|
|
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION [9116]
|
Facility
IP
|
$5.04
|
|
|
Service Code
|
CPT J7197
|
| Hospital Charge Code |
1720745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Blue Shield of California Commercial |
$3.59
|
| Rate for Payer: Blue Shield of California EPN |
$2.58
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.53
|
| Rate for Payer: Cigna of CA PPO |
$3.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.02
|
| Rate for Payer: Galaxy Health WC |
$4.28
|
| Rate for Payer: Global Benefits Group Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
| Rate for Payer: Networks By Design Commercial |
$2.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.28
|
|
|
ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT INTRAVENOUS SOLUTION [9116]
|
Facility
OP
|
$5.04
|
|
|
Service Code
|
CPT J7197
|
| Hospital Charge Code |
1720745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$24.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.49
|
| Rate for Payer: BCBS Transplant Transplant |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.71
|
| Rate for Payer: Blue Shield of California EPN |
$4.66
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO |
$3.53
|
| Rate for Payer: Cigna of CA PPO |
$3.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.81
|
| Rate for Payer: Dignity Health Media |
$3.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.23
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3.87
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.87
|
| Rate for Payer: Galaxy Health WC |
$4.28
|
| Rate for Payer: Global Benefits Group Commercial |
$3.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.35
|
| Rate for Payer: Heritage Provider Network Transplant |
$6.35
|
| Rate for Payer: IEHP Medi-Cal |
$6.27
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$6.27
|
| Rate for Payer: IEHP Medicare Advantage |
$3.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.19
|
| Rate for Payer: Multiplan Commercial |
$4.03
|
| Rate for Payer: Networks By Design Commercial |
$2.52
|
| Rate for Payer: Prime Health Services Commercial |
$4.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO |
$2.52
|
| Rate for Payer: United Healthcare HMO Rider |
$2.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.26
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION [24585]
|
Facility
IP
|
$1,224.89
|
|
|
Service Code
|
CPT J7511
|
| Hospital Charge Code |
1759922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$293.97 |
| Max. Negotiated Rate |
$1,041.16 |
| Rate for Payer: Blue Shield of California Commercial |
$872.12
|
| Rate for Payer: Blue Shield of California EPN |
$627.14
|
| Rate for Payer: Cash Price |
$551.20
|
| Rate for Payer: Cigna of CA HMO |
$857.42
|
| Rate for Payer: Cigna of CA PPO |
$857.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$489.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$489.96
|
| Rate for Payer: Galaxy Health WC |
$1,041.16
|
| Rate for Payer: Global Benefits Group Commercial |
$734.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$817.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$466.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$293.97
|
| Rate for Payer: Multiplan Commercial |
$979.91
|
| Rate for Payer: Networks By Design Commercial |
$612.44
|
| Rate for Payer: Prime Health Services Commercial |
$1,041.16
|
|
|
ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION [24585]
|
Facility
OP
|
$1,224.89
|
|
|
Service Code
|
CPT J7511
|
| Hospital Charge Code |
1759922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$293.97 |
| Max. Negotiated Rate |
$5,843.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,843.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,161.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,021.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,021.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$523.04
|
| Rate for Payer: BCBS Transplant Transplant |
$734.93
|
| Rate for Payer: Blue Shield of California Commercial |
$902.74
|
| Rate for Payer: Blue Shield of California EPN |
$1,007.77
|
| Rate for Payer: Cash Price |
$551.20
|
| Rate for Payer: Cash Price |
$551.20
|
| Rate for Payer: Cigna of CA HMO |
$857.42
|
| Rate for Payer: Cigna of CA PPO |
$857.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,393.54
|
| Rate for Payer: Dignity Health Media |
$929.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,021.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,254.19
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$929.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$929.03
|
| Rate for Payer: Galaxy Health WC |
$1,041.16
|
| Rate for Payer: Global Benefits Group Commercial |
$734.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$918.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,523.60
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,523.60
|
| Rate for Payer: IEHP Medi-Cal |
$1,505.02
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$1,505.02
|
| Rate for Payer: IEHP Medicare Advantage |
$929.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$817.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$466.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$929.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$293.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,170.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,244.89
|
| Rate for Payer: Multiplan Commercial |
$979.91
|
| Rate for Payer: Networks By Design Commercial |
$612.44
|
| Rate for Payer: Prime Health Services Commercial |
$1,041.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$734.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$734.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$612.44
|
| Rate for Payer: United Healthcare All Other HMO |
$612.44
|
| Rate for Payer: United Healthcare HMO Rider |
$612.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$612.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,393.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,021.93
|
| Rate for Payer: Vantage Medical Group Senior |
$929.03
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]
|
Facility
OP
|
$1,584.00
|
|
|
Service Code
|
CPT J0841
|
| Hospital Charge Code |
ERX222871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$380.16 |
| Max. Negotiated Rate |
$5,736.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,736.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,140.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,003.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,003.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,600.44
|
| Rate for Payer: BCBS Transplant Transplant |
$950.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1,167.41
|
| Rate for Payer: Blue Shield of California EPN |
$1,464.00
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cigna of CA HMO |
$1,108.80
|
| Rate for Payer: Cigna of CA PPO |
$1,108.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,368.11
|
| Rate for Payer: Dignity Health Media |
$912.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,003.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,231.30
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$912.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$912.08
|
| Rate for Payer: Galaxy Health WC |
$1,346.40
|
| Rate for Payer: Global Benefits Group Commercial |
$950.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,188.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,495.80
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,495.80
|
| Rate for Payer: IEHP Medi-Cal |
$1,477.56
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$1,477.56
|
| Rate for Payer: IEHP Medicare Advantage |
$912.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,056.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,741.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$912.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$380.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,149.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,222.18
|
| Rate for Payer: Multiplan Commercial |
$1,267.20
|
| Rate for Payer: Networks By Design Commercial |
$792.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,346.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$950.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$950.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$792.00
|
| Rate for Payer: United Healthcare All Other HMO |
$792.00
|
| Rate for Payer: United Healthcare HMO Rider |
$792.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$792.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,368.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,003.28
|
| Rate for Payer: Vantage Medical Group Senior |
$912.08
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]
|
Facility
IP
|
$1,584.00
|
|
|
Service Code
|
CPT J0841
|
| Hospital Charge Code |
ERX222871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$380.16 |
| Max. Negotiated Rate |
$1,346.40 |
| Rate for Payer: Blue Shield of California Commercial |
$1,127.81
|
| Rate for Payer: Blue Shield of California EPN |
$811.01
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cigna of CA HMO |
$1,108.80
|
| Rate for Payer: Cigna of CA PPO |
$1,108.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$633.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$633.60
|
| Rate for Payer: Galaxy Health WC |
$1,346.40
|
| Rate for Payer: Global Benefits Group Commercial |
$950.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,056.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$603.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$380.16
|
| Rate for Payer: Multiplan Commercial |
$1,267.20
|
| Rate for Payer: Networks By Design Commercial |
$792.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,346.40
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
ERX199666
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.68
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Media |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
ERX199666
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.68
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Media |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.68
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Media |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$30,166.55
|
|
|
Service Code
|
APR-DRG 2333
|
| Min. Negotiated Rate |
$23,140.92 |
| Max. Negotiated Rate |
$30,166.55 |
| Rate for Payer: IEHP Medi-Cal |
$23,140.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,166.55
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$20,816.88
|
|
|
Service Code
|
APR-DRG 2332
|
| Min. Negotiated Rate |
$15,968.73 |
| Max. Negotiated Rate |
$20,816.88 |
| Rate for Payer: IEHP Medi-Cal |
$15,968.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,816.88
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$16,118.97
|
|
|
Service Code
|
APR-DRG 2331
|
| Min. Negotiated Rate |
$12,364.95 |
| Max. Negotiated Rate |
$16,118.97 |
| Rate for Payer: IEHP Medi-Cal |
$12,364.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,118.97
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$45,127.47
|
|
|
Service Code
|
APR-DRG 2334
|
| Min. Negotiated Rate |
$34,617.52 |
| Max. Negotiated Rate |
$45,127.47 |
| Rate for Payer: IEHP Medi-Cal |
$34,617.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45,127.47
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$24,823.12
|
|
|
Service Code
|
APR-DRG 2343
|
| Min. Negotiated Rate |
$19,041.95 |
| Max. Negotiated Rate |
$24,823.12 |
| Rate for Payer: IEHP Medi-Cal |
$19,041.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,823.12
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$16,883.34
|
|
|
Service Code
|
APR-DRG 2342
|
| Min. Negotiated Rate |
$12,951.30 |
| Max. Negotiated Rate |
$16,883.34 |
| Rate for Payer: IEHP Medi-Cal |
$12,951.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,883.34
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$42,273.97
|
|
|
Service Code
|
APR-DRG 2344
|
| Min. Negotiated Rate |
$32,428.59 |
| Max. Negotiated Rate |
$42,273.97 |
| Rate for Payer: IEHP Medi-Cal |
$32,428.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42,273.97
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$13,072.17
|
|
|
Service Code
|
APR-DRG 2341
|
| Min. Negotiated Rate |
$10,027.73 |
| Max. Negotiated Rate |
$13,072.17 |
| Rate for Payer: IEHP Medi-Cal |
$10,027.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,072.17
|
|
