|
MUPIROCIN 2 % TOPICAL OINTMENT [10674]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 45802-112-22
|
| Hospital Charge Code |
1743673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$95,085.82
|
|
|
Service Code
|
APR-DRG 9124
|
| Min. Negotiated Rate |
$72,940.84 |
| Max. Negotiated Rate |
$95,085.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$72,940.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$95,085.82
|
|
|
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$33,772.01
|
|
|
Service Code
|
APR-DRG 9122
|
| Min. Negotiated Rate |
$25,906.68 |
| Max. Negotiated Rate |
$33,772.01 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,906.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,772.01
|
|
|
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$53,553.17
|
|
|
Service Code
|
APR-DRG 9123
|
| Min. Negotiated Rate |
$41,080.92 |
| Max. Negotiated Rate |
$53,553.17 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41,080.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53,553.17
|
|
|
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$33,298.49
|
|
|
Service Code
|
APR-DRG 9121
|
| Min. Negotiated Rate |
$25,543.45 |
| Max. Negotiated Rate |
$33,298.49 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,543.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,298.49
|
|
|
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY
|
Facility
|
IP
|
$14,150.44
|
|
|
Service Code
|
APR-DRG 3432
|
| Min. Negotiated Rate |
$10,854.88 |
| Max. Negotiated Rate |
$14,150.44 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,854.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,150.44
|
|
|
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY
|
Facility
|
IP
|
$12,040.02
|
|
|
Service Code
|
APR-DRG 3431
|
| Min. Negotiated Rate |
$9,235.96 |
| Max. Negotiated Rate |
$12,040.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,235.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,040.02
|
|
|
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY
|
Facility
|
IP
|
$33,482.92
|
|
|
Service Code
|
APR-DRG 3434
|
| Min. Negotiated Rate |
$25,684.92 |
| Max. Negotiated Rate |
$33,482.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,684.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,482.92
|
|
|
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY
|
Facility
|
IP
|
$20,678.54
|
|
|
Service Code
|
APR-DRG 3433
|
| Min. Negotiated Rate |
$15,862.61 |
| Max. Negotiated Rate |
$20,678.54 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,862.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,678.54
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [196255]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
NDG40810660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [196255]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
NDG40810660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Blue Distinction Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Media |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO |
$0.68
|
| Rate for Payer: United Healthcare HMO Rider |
$0.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
OP
|
$1.61
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
1765018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.96
|
| Rate for Payer: Blue Distinction Transplant |
$0.97
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.37
|
| Rate for Payer: Dignity Health Media |
$1.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Vantage Medical Group Senior |
$1.37
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
NDG40810660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
| Rate for Payer: Blue Distinction Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$1.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: Dignity Health Media |
$1.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other HMO |
$0.68
|
| Rate for Payer: United Healthcare HMO Rider |
$0.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
1765018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Prime Health Services Commercial |
$1.37
|
|
|
MVI ADULT WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION. [40810661]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
NDC 54643-5650-2
|
| Hospital Charge Code |
NDG40810660
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.97
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.88
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
NDG117200B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.06
|
| Rate for Payer: Blue Distinction Transplant |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$3.78
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$3.28
|
| Rate for Payer: Cigna of CA PPO |
$3.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Media |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2.56
|
| Rate for Payer: United Healthcare HMO Rider |
$2.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.02
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
NDG117200A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Blue Shield of California Commercial |
$3.57
|
| Rate for Payer: Blue Shield of California EPN |
$2.57
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Galaxy Health WC |
$4.27
|
| Rate for Payer: Global Benefits Group Commercial |
$3.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.02
|
| Rate for Payer: Networks By Design Commercial |
$3.26
|
| Rate for Payer: Prime Health Services Commercial |
$4.27
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
OP
|
$5.02
|
|
|
Service Code
|
NDC 54643-5646-1
|
| Hospital Charge Code |
NDG117200A
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.99
|
| Rate for Payer: Blue Distinction Transplant |
$3.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.70
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna of CA HMO |
$3.21
|
| Rate for Payer: Cigna of CA PPO |
$3.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.27
|
| Rate for Payer: Dignity Health Media |
$4.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.01
|
| Rate for Payer: Galaxy Health WC |
$4.27
|
| Rate for Payer: Global Benefits Group Commercial |
$3.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.02
|
| Rate for Payer: Networks By Design Commercial |
$3.26
|
| Rate for Payer: Prime Health Services Commercial |
$4.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.51
|
| Rate for Payer: United Healthcare All Other HMO |
$2.51
|
| Rate for Payer: United Healthcare HMO Rider |
$2.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: Vantage Medical Group Senior |
$4.27
|
|
|
MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT-200 MCG/5 ML INTRAVENOUS SOLN [117200]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 54643-5647-0
|
| Hospital Charge Code |
NDG117200B
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Blue Shield of California Commercial |
$3.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Galaxy Health WC |
$4.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$3.33
|
| Rate for Payer: Prime Health Services Commercial |
$4.36
|
|
|
MVI, PEDI NO.2 WITH VIT K 80 MG-400 UNIT-200 MCG INTRAVENOUS SOLUTION [197135]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 61703-421-53
|
| Hospital Charge Code |
ERX197135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Blue Shield of California Commercial |
$10.82
|
| Rate for Payer: Blue Shield of California EPN |
$7.78
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.08
|
| Rate for Payer: Galaxy Health WC |
$12.92
|
| Rate for Payer: Global Benefits Group Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: Multiplan Commercial |
$12.16
|
| Rate for Payer: Networks By Design Commercial |
$9.88
|
| Rate for Payer: Prime Health Services Commercial |
$12.92
|
|
|
MVI, PEDI NO.2 WITH VIT K 80 MG-400 UNIT-200 MCG INTRAVENOUS SOLUTION [197135]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 61703-421-53
|
| Hospital Charge Code |
ERX197135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.06
|
| Rate for Payer: Blue Distinction Transplant |
$9.12
|
| Rate for Payer: Blue Shield of California Commercial |
$11.20
|
| Rate for Payer: Blue Shield of California EPN |
$8.88
|
| Rate for Payer: Cash Price |
$6.84
|
| Rate for Payer: Cigna of CA HMO |
$9.73
|
| Rate for Payer: Cigna of CA PPO |
$11.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.92
|
| Rate for Payer: Dignity Health Media |
$12.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.08
|
| Rate for Payer: Galaxy Health WC |
$12.92
|
| Rate for Payer: Global Benefits Group Commercial |
$9.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: Multiplan Commercial |
$12.16
|
| Rate for Payer: Networks By Design Commercial |
$9.88
|
| Rate for Payer: Prime Health Services Commercial |
$12.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.60
|
| Rate for Payer: United Healthcare All Other HMO |
$7.60
|
| Rate for Payer: United Healthcare HMO Rider |
$7.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.92
|
| Rate for Payer: Vantage Medical Group Senior |
$12.92
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
CPT J7519
|
| Hospital Charge Code |
1756520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.88 |
| Max. Negotiated Rate |
$73.95 |
| Rate for Payer: Blue Shield of California Commercial |
$61.94
|
| Rate for Payer: Blue Shield of California Commercial |
$92.25
|
| Rate for Payer: Blue Shield of California EPN |
$44.54
|
| Rate for Payer: Blue Shield of California EPN |
$66.34
|
| Rate for Payer: Cash Price |
$39.15
|
| Rate for Payer: Cash Price |
$58.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.83
|
| Rate for Payer: Galaxy Health WC |
$73.95
|
| Rate for Payer: Galaxy Health WC |
$110.13
|
| Rate for Payer: Global Benefits Group Commercial |
$77.74
|
| Rate for Payer: Global Benefits Group Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$86.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.10
|
| Rate for Payer: Multiplan Commercial |
$103.66
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: Networks By Design Commercial |
$84.22
|
| Rate for Payer: Networks By Design Commercial |
$56.55
|
| Rate for Payer: Prime Health Services Commercial |
$110.13
|
| Rate for Payer: Prime Health Services Commercial |
$73.95
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION [23968]
|
Facility
|
OP
|
$129.57
|
|
|
Service Code
|
CPT J7519
|
| Hospital Charge Code |
1756520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$110.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$77.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.83
|
| Rate for Payer: Blue Distinction Transplant |
$77.74
|
| Rate for Payer: Blue Distinction Transplant |
$52.20
|
| Rate for Payer: Blue Shield of California Commercial |
$95.49
|
| Rate for Payer: Blue Shield of California Commercial |
$64.12
|
| Rate for Payer: Blue Shield of California EPN |
$75.67
|
| Rate for Payer: Blue Shield of California EPN |
$50.81
|
| Rate for Payer: Cash Price |
$58.31
|
| Rate for Payer: Cash Price |
$39.15
|
| Rate for Payer: Cash Price |
$58.31
|
| Rate for Payer: Cash Price |
$39.15
|
| Rate for Payer: Cigna of CA HMO |
$82.92
|
| Rate for Payer: Cigna of CA HMO |
$55.68
|
| Rate for Payer: Cigna of CA PPO |
$95.88
|
| Rate for Payer: Cigna of CA PPO |
$64.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Media |
$0.73
|
| Rate for Payer: Dignity Health Media |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.73
|
| Rate for Payer: Galaxy Health WC |
$73.95
|
| Rate for Payer: Galaxy Health WC |
$110.13
|
| Rate for Payer: Global Benefits Group Commercial |
$77.74
|
| Rate for Payer: Global Benefits Group Commercial |
$52.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$97.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$65.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Transplant |
$1.19
|
| Rate for Payer: Heritage Provider Network Transplant |
$1.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$1.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$1.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$86.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$58.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$103.66
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: Networks By Design Commercial |
$56.55
|
| Rate for Payer: Networks By Design Commercial |
$84.22
|
| Rate for Payer: Prime Health Services Commercial |
$73.95
|
| Rate for Payer: Prime Health Services Commercial |
$110.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$52.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$77.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$52.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$77.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$64.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$43.50
|
| Rate for Payer: United Healthcare All Other HMO |
$64.78
|
| Rate for Payer: United Healthcare All Other HMO |
$43.50
|
| Rate for Payer: United Healthcare HMO Rider |
$43.50
|
| Rate for Payer: United Healthcare HMO Rider |
$64.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$43.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$64.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSPENSION [25005]
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1715194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Blue Shield of California Commercial |
$2.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.37
|
| Rate for Payer: Cigna of CA PPO |
$2.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
| Rate for Payer: Networks By Design Commercial |
$1.70
|
| Rate for Payer: Prime Health Services Commercial |
$2.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.12
|
|
|
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSPENSION [25005]
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
CPT J7517
|
| Hospital Charge Code |
1715194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.97
|
| Rate for Payer: Blue Distinction Transplant |
$2.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cigna of CA HMO |
$2.37
|
| Rate for Payer: Cigna of CA PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.88
|
| Rate for Payer: Dignity Health Media |
$2.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.36
|
| Rate for Payer: Galaxy Health WC |
$2.88
|
| Rate for Payer: Global Benefits Group Commercial |
$2.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$2.71
|
| Rate for Payer: Networks By Design Commercial |
$1.70
|
| Rate for Payer: Prime Health Services Commercial |
$2.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: Vantage Medical Group Senior |
$2.88
|
|
