|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Blue Shield of California Commercial |
$83.27
|
| Rate for Payer: Blue Shield of California EPN |
$59.88
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
OP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.13 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$153.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$128.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$128.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.35
|
| Rate for Payer: BCBS Transplant Transplant |
$140.33
|
| Rate for Payer: Blue Shield of California Commercial |
$172.38
|
| Rate for Payer: Blue Shield of California EPN |
$136.59
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$198.81
|
| Rate for Payer: Dignity Health Media |
$198.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$198.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$175.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.13
|
| Rate for Payer: Multiplan Commercial |
$187.11
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$140.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$140.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$140.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.94
|
| Rate for Payer: United Healthcare All Other HMO |
$116.94
|
| Rate for Payer: United Healthcare HMO Rider |
$116.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$198.81
|
| Rate for Payer: Vantage Medical Group Senior |
$198.81
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
IP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.13 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Blue Shield of California Commercial |
$166.53
|
| Rate for Payer: Blue Shield of California EPN |
$119.75
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.13
|
| Rate for Payer: Multiplan Commercial |
$187.11
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
OP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: BCBS Transplant Transplant |
$29.66
|
| Rate for Payer: Blue Shield of California Commercial |
$36.44
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: Dignity Health Media |
$42.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$37.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.72
|
| Rate for Payer: United Healthcare All Other HMO |
$24.72
|
| Rate for Payer: United Healthcare HMO Rider |
$24.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
IP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Blue Shield of California Commercial |
$35.20
|
| Rate for Payer: Blue Shield of California EPN |
$25.31
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$7.96
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: BCBS Transplant Transplant |
$9.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Media |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.77
|
| Rate for Payer: United Healthcare HMO Rider |
$7.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$7.96
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: BCBS Transplant Transplant |
$9.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Media |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.77
|
| Rate for Payer: United Healthcare HMO Rider |
$7.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
IP
|
$53,968.17
|
|
|
Service Code
|
APR-DRG 1791
|
| Min. Negotiated Rate |
$41,399.27 |
| Max. Negotiated Rate |
$53,968.17 |
| Rate for Payer: IEHP Medi-Cal |
$41,399.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53,968.17
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
IP
|
$61,161.32
|
|
|
Service Code
|
APR-DRG 1792
|
| Min. Negotiated Rate |
$46,917.17 |
| Max. Negotiated Rate |
$61,161.32 |
| Rate for Payer: IEHP Medi-Cal |
$46,917.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61,161.32
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
IP
|
$102,947.59
|
|
|
Service Code
|
APR-DRG 1794
|
| Min. Negotiated Rate |
$78,971.64 |
| Max. Negotiated Rate |
$102,947.59 |
| Rate for Payer: IEHP Medi-Cal |
$78,971.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102,947.59
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
IP
|
$75,065.24
|
|
|
Service Code
|
APR-DRG 1793
|
| Min. Negotiated Rate |
$57,582.94 |
| Max. Negotiated Rate |
$75,065.24 |
| Rate for Payer: IEHP Medi-Cal |
$57,582.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75,065.24
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
IP
|
$479.52
|
|
|
Service Code
|
NDC 68727-800-02
|
| Hospital Charge Code |
NDG4081463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$407.59 |
| Rate for Payer: Blue Shield of California Commercial |
$341.42
|
| Rate for Payer: Blue Shield of California EPN |
$245.51
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cigna of CA HMO |
$335.66
|
| Rate for Payer: Cigna of CA PPO |
$335.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$191.81
|
| Rate for Payer: Galaxy Health WC |
$407.59
|
| Rate for Payer: Global Benefits Group Commercial |
$287.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$383.62
|
| Rate for Payer: Networks By Design Commercial |
$239.76
|
| Rate for Payer: Prime Health Services Commercial |
$407.59
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
OP
|
$479.52
|
|
|
Service Code
|
NDC 68727-800-02
|
| Hospital Charge Code |
NDG4081463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$407.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$314.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$407.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$263.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$263.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$285.70
|
| Rate for Payer: BCBS Transplant Transplant |
$287.71
|
| Rate for Payer: Blue Shield of California Commercial |
$353.41
|
| Rate for Payer: Blue Shield of California EPN |
$280.04
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cigna of CA HMO |
$335.66
|
| Rate for Payer: Cigna of CA PPO |
$335.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$407.59
|
| Rate for Payer: Dignity Health Media |
$407.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$191.81
|
| Rate for Payer: Galaxy Health WC |
$407.59
|
| Rate for Payer: Global Benefits Group Commercial |
$287.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$359.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$383.62
|
| Rate for Payer: Networks By Design Commercial |
$239.76
|
| Rate for Payer: Prime Health Services Commercial |
$407.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$287.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$287.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$239.76
|
| Rate for Payer: United Healthcare All Other HMO |
$239.76
|
| Rate for Payer: United Healthcare HMO Rider |
$239.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$239.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$407.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.59
|
| Rate for Payer: Vantage Medical Group Senior |
$407.59
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
IP
|
$479.52
|
|
|
Service Code
|
NDC 68727-800-01
|
| Hospital Charge Code |
NDG4081463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$407.59 |
| Rate for Payer: Blue Shield of California Commercial |
$341.42
|
| Rate for Payer: Blue Shield of California EPN |
$245.51
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cigna of CA HMO |
$335.66
|
| Rate for Payer: Cigna of CA PPO |
$335.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$191.81
|
| Rate for Payer: Galaxy Health WC |
$407.59
|
| Rate for Payer: Global Benefits Group Commercial |
$287.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$383.62
|
| Rate for Payer: Networks By Design Commercial |
$239.76
|
| Rate for Payer: Prime Health Services Commercial |
$407.59
|
|
|
DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION [214034]
|
Facility
OP
|
$479.52
|
|
|
Service Code
|
NDC 68727-800-01
|
| Hospital Charge Code |
NDG4081463
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.08 |
| Max. Negotiated Rate |
$407.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$314.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$407.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$263.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$263.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$285.70
|
| Rate for Payer: BCBS Transplant Transplant |
$287.71
|
| Rate for Payer: Blue Shield of California Commercial |
$353.41
|
| Rate for Payer: Blue Shield of California EPN |
$280.04
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cash Price |
$215.78
|
| Rate for Payer: Cigna of CA HMO |
$335.66
|
| Rate for Payer: Cigna of CA PPO |
$335.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$407.59
|
| Rate for Payer: Dignity Health Media |
$407.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$407.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$191.81
|
| Rate for Payer: Galaxy Health WC |
$407.59
|
| Rate for Payer: Global Benefits Group Commercial |
$287.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$359.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$319.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$182.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.08
|
| Rate for Payer: Multiplan Commercial |
$383.62
|
| Rate for Payer: Networks By Design Commercial |
$239.76
|
| Rate for Payer: Prime Health Services Commercial |
$407.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$287.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$287.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$239.76
|
| Rate for Payer: United Healthcare All Other HMO |
$239.76
|
| Rate for Payer: United Healthcare HMO Rider |
$239.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$239.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$407.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$407.59
|
| Rate for Payer: Vantage Medical Group Senior |
$407.59
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS
|
Facility
IP
|
$13,144.88
|
|
|
Service Code
|
APR-DRG 0422
|
| Min. Negotiated Rate |
$10,083.51 |
| Max. Negotiated Rate |
$13,144.88 |
| Rate for Payer: IEHP Medi-Cal |
$10,083.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,144.88
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS
|
Facility
IP
|
$10,357.01
|
|
|
Service Code
|
APR-DRG 0421
|
| Min. Negotiated Rate |
$7,944.92 |
| Max. Negotiated Rate |
$10,357.01 |
| Rate for Payer: IEHP Medi-Cal |
$7,944.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,357.01
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS
|
Facility
IP
|
$31,493.11
|
|
|
Service Code
|
APR-DRG 0424
|
| Min. Negotiated Rate |
$24,158.53 |
| Max. Negotiated Rate |
$31,493.11 |
| Rate for Payer: IEHP Medi-Cal |
$24,158.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,493.11
|
|
|
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS
|
Facility
IP
|
$17,686.72
|
|
|
Service Code
|
APR-DRG 0423
|
| Min. Negotiated Rate |
$13,567.58 |
| Max. Negotiated Rate |
$17,686.72 |
| Rate for Payer: IEHP Medi-Cal |
$13,567.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,686.72
|
|
|
DEMECLOCYCLINE 150 MG TABLET [9726]
|
Facility
OP
|
$8.32
|
|
|
Service Code
|
NDC 62584-159-01
|
| Hospital Charge Code |
1711453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.96
|
| Rate for Payer: BCBS Transplant Transplant |
$4.99
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.82
|
| Rate for Payer: Cigna of CA PPO |
$5.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.07
|
| Rate for Payer: Dignity Health Media |
$7.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.33
|
| Rate for Payer: Galaxy Health WC |
$7.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Networks By Design Commercial |
$5.41
|
| Rate for Payer: Prime Health Services Commercial |
$7.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Other HMO |
$4.16
|
| Rate for Payer: United Healthcare HMO Rider |
$4.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.07
|
| Rate for Payer: Vantage Medical Group Senior |
$7.07
|
|
|
DEMECLOCYCLINE 150 MG TABLET [9726]
|
Facility
IP
|
$8.32
|
|
|
Service Code
|
NDC 62584-159-11
|
| Hospital Charge Code |
1711453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.07 |
| Rate for Payer: Blue Shield of California Commercial |
$5.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.26
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.82
|
| Rate for Payer: Cigna of CA PPO |
$5.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Galaxy Health WC |
$7.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Networks By Design Commercial |
$5.41
|
| Rate for Payer: Prime Health Services Commercial |
$7.07
|
|
|
DEMECLOCYCLINE 150 MG TABLET [9726]
|
Facility
OP
|
$8.32
|
|
|
Service Code
|
NDC 62584-159-11
|
| Hospital Charge Code |
1711453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.96
|
| Rate for Payer: BCBS Transplant Transplant |
$4.99
|
| Rate for Payer: Blue Shield of California Commercial |
$6.13
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.82
|
| Rate for Payer: Cigna of CA PPO |
$5.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.07
|
| Rate for Payer: Dignity Health Media |
$7.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.33
|
| Rate for Payer: Galaxy Health WC |
$7.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Networks By Design Commercial |
$5.41
|
| Rate for Payer: Prime Health Services Commercial |
$7.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Other HMO |
$4.16
|
| Rate for Payer: United Healthcare HMO Rider |
$4.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.07
|
| Rate for Payer: Vantage Medical Group Senior |
$7.07
|
|
|
DEMECLOCYCLINE 150 MG TABLET [9726]
|
Facility
IP
|
$8.32
|
|
|
Service Code
|
NDC 62584-159-01
|
| Hospital Charge Code |
1711453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$7.07 |
| Rate for Payer: Blue Shield of California Commercial |
$5.92
|
| Rate for Payer: Blue Shield of California EPN |
$4.26
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cigna of CA HMO |
$5.82
|
| Rate for Payer: Cigna of CA PPO |
$5.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Galaxy Health WC |
$7.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Networks By Design Commercial |
$5.41
|
| Rate for Payer: Prime Health Services Commercial |
$7.07
|
|
