|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$18,449.99
|
|
|
Service Code
|
APR-DRG 4233
|
| Min. Negotiated Rate |
$11,652.62 |
| Max. Negotiated Rate |
$18,449.99 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,652.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,886.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,449.99
|
|
|
INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11106
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$233.73 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$950.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$1,239.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,568.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1,045.63
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,558.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$233.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$258.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,330.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$950.57
|
| Rate for Payer: Preferred Health Network WC |
$1,264.53
|
| Rate for Payer: Prime Health Services Medicare |
$1,007.60
|
| Rate for Payer: Prime Health Services WC |
$1,226.59
|
| Rate for Payer: Riverside University Health System MISP |
$1,045.63
|
| Rate for Payer: United Healthcare All Other HMO |
$4,460.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,591.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,374.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$950.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 21501
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$87.74 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,735.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,735.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$5,794.14
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,109.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,735.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,164.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4,109.55
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,126.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$87.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$96.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,230.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,006.17
|
| Rate for Payer: Multiplan WC |
$5,794.14
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Preferred Health Network WC |
$5,912.39
|
| Rate for Payer: Prime Health Services Medicare |
$3,960.11
|
| Rate for Payer: Prime Health Services WC |
$5,735.02
|
| Rate for Payer: Riverside University Health System MISP |
$4,109.55
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$3,735.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Vantage Medical Group Senior |
$3,735.95
|
|
|
INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 23030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$96.70 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,735.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,735.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$5,794.14
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,109.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,735.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,164.32
|
| Rate for Payer: EPIC Health Plan Senior |
$4,109.55
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,126.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$96.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,230.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,006.17
|
| Rate for Payer: Multiplan WC |
$5,794.14
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Preferred Health Network WC |
$5,912.39
|
| Rate for Payer: Prime Health Services Medicare |
$3,960.11
|
| Rate for Payer: Prime Health Services WC |
$5,735.02
|
| Rate for Payer: Riverside University Health System MISP |
$4,109.55
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$3,735.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Vantage Medical Group Senior |
$3,735.95
|
|
|
INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 10121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$418.58 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,124.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,124.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,280.13
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,336.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,124.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,504.98
|
| Rate for Payer: EPIC Health Plan Senior |
$2,336.65
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,483.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$418.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,124.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$462.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,973.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,846.47
|
| Rate for Payer: Multiplan WC |
$3,280.13
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,124.23
|
| Rate for Payer: Preferred Health Network WC |
$3,347.07
|
| Rate for Payer: Prime Health Services Medicare |
$2,251.68
|
| Rate for Payer: Prime Health Services WC |
$3,246.66
|
| Rate for Payer: Riverside University Health System MISP |
$2,336.65
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,124.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2,124.23
|
|
|
INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 25000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$318.91 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,068.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,240.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,036.70
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,412.45
|
| Rate for Payer: EPIC Health Plan Senior |
$2,274.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,391.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$318.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$352.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,895.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Preferred Health Network WC |
$3,306.12
|
| Rate for Payer: Prime Health Services Medicare |
$2,192.24
|
| Rate for Payer: Prime Health Services WC |
$3,206.94
|
| Rate for Payer: Riverside University Health System MISP |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,068.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
IP
|
$2,984.99
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$597.00 |
| Max. Negotiated Rate |
$2,686.49 |
| Rate for Payer: Adventist Health Commercial |
$597.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,393.96
|
| Rate for Payer: Blue Shield of California EPN |
$1,504.43
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Central Health Plan Commercial |
$2,387.99
|
| Rate for Payer: Cigna of CA HMO |
$2,089.49
|
| Rate for Payer: Cigna of CA PPO |
$2,089.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,089.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,194.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1,194.00
|
| Rate for Payer: Galaxy Health WC |
$2,537.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1,790.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,686.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,895.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,761.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$597.00
|
| Rate for Payer: Multiplan Commercial |
$2,238.74
|
| Rate for Payer: Networks By Design Commercial |
$1,492.49
|
| Rate for Payer: Prime Health Services Commercial |
$2,537.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,120.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1,090.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1,066.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$977.58
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
OP
|
$2,984.99
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.90 |
| Max. Negotiated Rate |
$2,686.49 |
| Rate for Payer: Adventist Health Commercial |
$597.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$12.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$76.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.33
|
| Rate for Payer: Blue Shield of California Commercial |
$15.87
|
| Rate for Payer: Blue Shield of California EPN |
$14.43
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Central Health Plan Commercial |
$2,387.99
|
| Rate for Payer: Cigna of CA HMO |
$2,089.49
|
| Rate for Payer: Cigna of CA PPO |
$2,089.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,089.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.30
|
| Rate for Payer: EPIC Health Plan Senior |
$14.20
|
| Rate for Payer: Galaxy Health WC |
$2,537.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1,790.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,686.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$21.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,895.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$597.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.30
|
| Rate for Payer: Multiplan Commercial |
$2,238.74
|
| Rate for Payer: Networks By Design Commercial |
$1,492.49
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$12.91
|
| Rate for Payer: Prime Health Services Commercial |
$2,537.24
|
| Rate for Payer: Prime Health Services Medicare |
$13.68
|
| Rate for Payer: Riverside University Health System MISP |
$14.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,790.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,790.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,120.27
|
| Rate for Payer: United Healthcare All Other HMO |
$1,090.42
|
| Rate for Payer: United Healthcare HMO Rider |
$1,066.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$977.58
|
| Rate for Payer: Upland Medical Group Pediatric |
$12.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.20
|
| Rate for Payer: Vantage Medical Group Senior |
$14.20
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$551.88 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Blue Shield of California Commercial |
$491.79
|
| Rate for Payer: Blue Shield of California EPN |
$309.05
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Central Health Plan Commercial |
$490.56
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$429.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.28
|
| Rate for Payer: EPIC Health Plan Senior |
$245.28
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$551.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$389.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$361.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$122.64
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$551.88 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Adventist Health Medi-Cal |
$5.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$33.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.57
|
| Rate for Payer: Blue Shield of California Commercial |
$6.85
|
| Rate for Payer: Blue Shield of California EPN |
$6.23
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Central Health Plan Commercial |
$490.56
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$429.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.73
|
| Rate for Payer: EPIC Health Plan Senior |
$5.82
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$551.88
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$389.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$122.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$5.29
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: Prime Health Services Medicare |
$5.61
|
| Rate for Payer: Riverside University Health System MISP |
$5.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$367.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$367.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: Vantage Medical Group Senior |
$5.82
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Adventist Health Medi-Cal |
$9.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.65
|
| Rate for Payer: Blue Shield of California Commercial |
$60.86
|
| Rate for Payer: Blue Shield of California EPN |
$38.30
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Central Health Plan Commercial |
$76.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.35
|
| Rate for Payer: EPIC Health Plan Senior |
$10.23
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.40
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$15.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$9.30
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Prime Health Services Medicare |
$9.86
|
| Rate for Payer: Riverside University Health System MISP |
$10.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
| Rate for Payer: Upland Medical Group Pediatric |
$9.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Blue Shield of California Commercial |
$76.99
|
| Rate for Payer: Blue Shield of California EPN |
$48.38
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Central Health Plan Commercial |
$76.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$86.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$60.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.20
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
IP
|
$4,608.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$921.60 |
| Max. Negotiated Rate |
$4,147.20 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3,695.62
|
| Rate for Payer: Blue Shield of California EPN |
$2,322.43
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Central Health Plan Commercial |
$3,686.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,225.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,843.20
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Management Network EPO/PPO |
$4,147.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,926.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,718.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$921.60
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: Networks By Design Commercial |
$2,995.20
|
| Rate for Payer: Prime Health Services Commercial |
$3,916.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,729.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1,683.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1,646.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,509.12
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
OP
|
$4,608.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$921.60 |
| Max. Negotiated Rate |
$22,246.36 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Adventist Health Medi-Cal |
$2,000.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,501.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,201.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,201.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17,826.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22,246.36
|
| Rate for Payer: Blue Shield of California Commercial |
$2,903.04
|
| Rate for Payer: Blue Shield of California EPN |
$1,829.38
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Central Health Plan Commercial |
$3,686.40
|
| 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 |
$2,501.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,201.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,201.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,225.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,301.55
|
| Rate for Payer: EPIC Health Plan Senior |
$2,201.03
|
| Rate for Payer: Galaxy Health WC |
$3,916.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,764.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,147.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,281.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,000.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,926.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,801.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$921.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,681.26
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: Networks By Design Commercial |
$2,995.20
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,000.94
|
| Rate for Payer: Prime Health Services Commercial |
$3,916.80
|
| Rate for Payer: Prime Health Services Medicare |
$2,121.00
|
| Rate for Payer: Riverside University Health System MISP |
$2,201.03
|
| 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 |
$1,729.38
|
| Rate for Payer: United Healthcare All Other HMO |
$1,683.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1,646.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,509.12
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,000.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,501.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,201.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2,201.03
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$244.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.90 |
| Max. Negotiated Rate |
$220.05 |
| Rate for Payer: Adventist Health Commercial |
$48.90
|
| Rate for Payer: Blue Shield of California Commercial |
$196.09
|
| Rate for Payer: Blue Shield of California EPN |
$123.23
|
| Rate for Payer: Cash Price |
$110.02
|
| Rate for Payer: Central Health Plan Commercial |
$195.60
|
| Rate for Payer: Cigna of CA HMO |
$171.15
|
| Rate for Payer: Cigna of CA PPO |
$171.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$171.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.80
|
| Rate for Payer: EPIC Health Plan Senior |
$97.80
|
| Rate for Payer: Galaxy Health WC |
$207.82
|
| Rate for Payer: Global Benefits Group Commercial |
$146.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$220.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$155.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$144.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.90
|
| Rate for Payer: Multiplan Commercial |
$183.38
|
| Rate for Payer: Networks By Design Commercial |
$122.25
|
| Rate for Payer: Prime Health Services Commercial |
$207.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.76
|
| Rate for Payer: United Healthcare All Other HMO |
$89.32
|
| Rate for Payer: United Healthcare HMO Rider |
$87.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$80.07
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$244.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.90 |
| Max. Negotiated Rate |
$220.05 |
| Rate for Payer: Adventist Health Commercial |
$48.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$148.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$207.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.38
|
| Rate for Payer: Blue Shield of California Commercial |
$155.01
|
| Rate for Payer: Blue Shield of California EPN |
$97.56
|
| Rate for Payer: Cash Price |
$110.02
|
| Rate for Payer: Central Health Plan Commercial |
$195.60
|
| Rate for Payer: Cigna of CA HMO |
$171.15
|
| Rate for Payer: Cigna of CA PPO |
$171.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$207.82
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$171.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.80
|
| Rate for Payer: EPIC Health Plan Senior |
$97.80
|
| Rate for Payer: Galaxy Health WC |
$207.82
|
| Rate for Payer: Global Benefits Group Commercial |
$146.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$220.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$155.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$144.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$171.15
|
| Rate for Payer: Multiplan Commercial |
$183.38
|
| Rate for Payer: Networks By Design Commercial |
$122.25
|
| Rate for Payer: Prime Health Services Commercial |
$207.82
|
| Rate for Payer: Riverside University Health System MISP |
$97.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$146.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$146.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.76
|
| Rate for Payer: United Healthcare All Other HMO |
$89.32
|
| Rate for Payer: United Healthcare HMO Rider |
$87.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$80.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.82
|
| Rate for Payer: Vantage Medical Group Senior |
$207.82
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$400.94 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$270.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Blue Shield of California Commercial |
$282.44
|
| Rate for Payer: Blue Shield of California EPN |
$177.75
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Central Health Plan Commercial |
$356.39
|
| Rate for Payer: Cigna of CA HMO |
$311.84
|
| Rate for Payer: Cigna of CA PPO |
$311.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$378.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$311.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$282.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$262.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: Networks By Design Commercial |
$222.75
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: Riverside University Health System MISP |
$178.20
|
| 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 |
$167.19
|
| Rate for Payer: United Healthcare All Other HMO |
$162.74
|
| Rate for Payer: United Healthcare HMO Rider |
$159.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$145.90
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$400.94 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Blue Shield of California Commercial |
$357.28
|
| Rate for Payer: Blue Shield of California EPN |
$224.53
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Central Health Plan Commercial |
$356.39
|
| Rate for Payer: Cigna of CA HMO |
$311.84
|
| Rate for Payer: Cigna of CA PPO |
$311.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$311.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$178.20
|
| Rate for Payer: EPIC Health Plan Senior |
$178.20
|
| Rate for Payer: Galaxy Health WC |
$378.67
|
| Rate for Payer: Global Benefits Group Commercial |
$267.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$400.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$282.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$262.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.10
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: Networks By Design Commercial |
$222.75
|
| Rate for Payer: Prime Health Services Commercial |
$378.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$167.19
|
| Rate for Payer: United Healthcare All Other HMO |
$162.74
|
| Rate for Payer: United Healthcare HMO Rider |
$159.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$145.90
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6846240601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| 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 5026843011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| 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 6846240601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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 Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| 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 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 5026843015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| 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
|
$0.43
|
|
|
Service Code
|
NDC 5026843015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| 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 5026843011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 6846230201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Senior |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
