|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
OP
|
$4,608.00
|
|
|
Service Code
|
CPT A9572
|
| Hospital Charge Code |
ERX13545
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,105.92 |
| Max. Negotiated Rate |
$19,199.50 |
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,916.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,534.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,534.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19,199.50
|
| Rate for Payer: BCBS Transplant Transplant |
$2,764.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2,723.33
|
| Rate for Payer: Blue Shield of California EPN |
$2,161.15
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna of CA HMO |
$2,949.12
|
| Rate for Payer: Cigna of CA PPO |
$3,409.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Dignity Health Media |
$3,916.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,916.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,843.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,843.20
|
| Rate for Payer: Galaxy Health WC |
$3,916.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,764.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,456.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,073.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,105.92
|
| Rate for Payer: Multiplan Commercial |
$3,686.40
|
| Rate for Payer: Networks By Design Commercial |
$2,995.20
|
| Rate for Payer: Prime Health Services Commercial |
$3,916.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2,764.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,764.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,764.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,304.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,304.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,304.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,304.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,916.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,916.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,916.80
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$75.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.46
|
| Rate for Payer: BCBS Transplant Transplant |
$82.03
|
| Rate for Payer: Blue Shield of California Commercial |
$100.76
|
| Rate for Payer: Blue Shield of California EPN |
$79.84
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO |
$87.50
|
| Rate for Payer: Cigna of CA PPO |
$101.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Media |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$102.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.36
|
| Rate for Payer: United Healthcare All Other HMO |
$68.36
|
| Rate for Payer: United Healthcare HMO Rider |
$68.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-02
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Blue Shield of California Commercial |
$97.34
|
| Rate for Payer: Blue Shield of California EPN |
$70.00
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
IP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Blue Shield of California Commercial |
$97.34
|
| Rate for Payer: Blue Shield of California EPN |
$70.00
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
OP
|
$136.72
|
|
|
Service Code
|
NDC 17478-701-25
|
| Hospital Charge Code |
1720205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$75.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$75.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$81.46
|
| Rate for Payer: BCBS Transplant Transplant |
$82.03
|
| Rate for Payer: Blue Shield of California Commercial |
$100.76
|
| Rate for Payer: Blue Shield of California EPN |
$79.84
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cash Price |
$61.52
|
| Rate for Payer: Cigna of CA HMO |
$87.50
|
| Rate for Payer: Cigna of CA PPO |
$101.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$116.21
|
| Rate for Payer: Dignity Health Media |
$116.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$54.69
|
| Rate for Payer: Galaxy Health WC |
$116.21
|
| Rate for Payer: Global Benefits Group Commercial |
$82.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$102.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$91.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.81
|
| Rate for Payer: Multiplan Commercial |
$109.38
|
| Rate for Payer: Networks By Design Commercial |
$88.87
|
| Rate for Payer: Prime Health Services Commercial |
$116.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$82.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$82.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.36
|
| Rate for Payer: United Healthcare All Other HMO |
$68.36
|
| Rate for Payer: United Healthcare HMO Rider |
$68.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$116.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.21
|
| Rate for Payer: Vantage Medical Group Senior |
$116.21
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
OP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$292.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$245.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$265.42
|
| Rate for Payer: BCBS Transplant Transplant |
$267.29
|
| Rate for Payer: Blue Shield of California Commercial |
$328.33
|
| Rate for Payer: Blue Shield of California EPN |
$260.17
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cigna of CA HMO |
$285.11
|
| Rate for Payer: Cigna of CA PPO |
$329.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Media |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$334.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$267.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$267.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$222.74
|
| Rate for Payer: United Healthcare All Other HMO |
$222.74
|
| Rate for Payer: United Healthcare HMO Rider |
$222.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$222.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
IP
|
$445.49
|
|
|
Service Code
|
NDC 63323-659-94
|
| Hospital Charge Code |
1753530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Blue Shield of California Commercial |
$317.19
|
| Rate for Payer: Blue Shield of California EPN |
$228.09
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$297.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.92
|
| Rate for Payer: Multiplan Commercial |
$356.39
|
| Rate for Payer: Networks By Design Commercial |
$289.57
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-15
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 50268-430-11
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 68462-406-01
|
| Hospital Charge Code |
1710358
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Media |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
IP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Media |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
OP
|
$0.39
|
|
|
Service Code
|
NDC 50268-431-11
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Media |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 68462-302-01
|
| Hospital Charge Code |
1710382
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
IP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
1748065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Blue Shield of California Commercial |
$309.21
|
| Rate for Payer: Blue Shield of California EPN |
$222.36
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
OP
|
$434.29
|
|
|
Service Code
|
NDC 69344-102-33
|
| Hospital Charge Code |
1748065
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$284.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$238.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.75
|
| Rate for Payer: BCBS Transplant Transplant |
$260.57
|
| Rate for Payer: Blue Shield of California Commercial |
$320.07
|
| Rate for Payer: Blue Shield of California EPN |
$253.63
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: Cigna of CA HMO |
$304.00
|
| Rate for Payer: Cigna of CA PPO |
$304.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Media |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$173.72
|
| Rate for Payer: Galaxy Health WC |
$369.15
|
| Rate for Payer: Global Benefits Group Commercial |
$260.57
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$325.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$289.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$165.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$104.23
|
| Rate for Payer: Multiplan Commercial |
$347.43
|
| Rate for Payer: Networks By Design Commercial |
$282.29
|
| Rate for Payer: Prime Health Services Commercial |
$369.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$260.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$260.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$260.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$217.14
|
| Rate for Payer: United Healthcare All Other HMO |
$217.14
|
| Rate for Payer: United Healthcare HMO Rider |
$217.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$217.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
1710396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Media |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 68462-325-60
|
| Hospital Charge Code |
1710396
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
Induced abortion, by dilation and evacuation
|
Facility
OP
|
$13,086.00
|
|
|
Service Code
|
CPT 59841
|
| Min. Negotiated Rate |
$673.42 |
| Max. Negotiated Rate |
$13,086.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13,086.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Media |
$3,906.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,273.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,906.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,406.14
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,406.14
|
| Rate for Payer: IEHP Medi-Cal |
$6,328.01
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$6,328.01
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$673.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,906.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,234.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
IP
|
$11,112.49
|
|
|
Service Code
|
APR-DRG 1133
|
| Min. Negotiated Rate |
$8,524.45 |
| Max. Negotiated Rate |
$11,112.49 |
| Rate for Payer: IEHP Medi-Cal |
$8,524.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,112.49
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
IP
|
$18,174.41
|
|
|
Service Code
|
APR-DRG 1134
|
| Min. Negotiated Rate |
$13,941.69 |
| Max. Negotiated Rate |
$18,174.41 |
| Rate for Payer: IEHP Medi-Cal |
$13,941.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,174.41
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
IP
|
$5,167.87
|
|
|
Service Code
|
APR-DRG 1131
|
| Min. Negotiated Rate |
$3,964.30 |
| Max. Negotiated Rate |
$5,167.87 |
| Rate for Payer: IEHP Medi-Cal |
$3,964.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,167.87
|
|
