|
KETOROLAC 30 MG/ML INJECTION. [4082473]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Adventist Health Commercial |
$1.57
|
| Rate for Payer: Adventist Health Commercial |
$1.37
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$6.06
|
| Rate for Payer: Blue Shield of California Commercial |
$5.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.45
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$6.27
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| Rate for Payer: Central Health Plan Commercial |
$1.68
|
| Rate for Payer: Central Health Plan Commercial |
$5.47
|
| Rate for Payer: Cigna of CA HMO |
$1.60
|
| Rate for Payer: Cigna of CA HMO |
$4.79
|
| Rate for Payer: Cigna of CA HMO |
$5.49
|
| Rate for Payer: Cigna of CA HMO |
$1.47
|
| Rate for Payer: Cigna of CA PPO |
$1.47
|
| Rate for Payer: Cigna of CA PPO |
$1.60
|
| Rate for Payer: Cigna of CA PPO |
$4.79
|
| Rate for Payer: Cigna of CA PPO |
$5.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Senior |
$0.91
|
| Rate for Payer: EPIC Health Plan Senior |
$3.14
|
| Rate for Payer: EPIC Health Plan Senior |
$2.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$5.81
|
| Rate for Payer: Galaxy Health WC |
$6.66
|
| Rate for Payer: Galaxy Health WC |
$1.78
|
| Rate for Payer: Global Benefits Group Commercial |
$4.10
|
| Rate for Payer: Global Benefits Group Commercial |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Global Benefits Group Commercial |
$4.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
| Rate for Payer: Networks By Design Commercial |
$3.92
|
| Rate for Payer: Networks By Design Commercial |
$1.05
|
| Rate for Payer: Networks By Design Commercial |
$3.42
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$5.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
| Rate for Payer: Prime Health Services Commercial |
$1.78
|
| Rate for Payer: Prime Health Services Commercial |
$6.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO |
$0.83
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.44
|
| Rate for Payer: United Healthcare HMO Rider |
$2.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.24
|
|
|
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION [91349]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Medi-Cal |
$0.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$0.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.44
|
| Rate for Payer: InnovAge PACE Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Prime Health Services Medicare |
$0.47
|
| Rate for Payer: Riverside University Health System MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Upland Medical Group Pediatric |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION [91349]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 76385-106-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Central Health Plan Commercial |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 72485-617-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 76385-106-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Central Health Plan Commercial |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.90
|
| Rate for Payer: InnovAge PACE Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
|
KETOTIFEN 0.025 % EYE DROPS [25471]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 72485-617-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.25
|
| Rate for Payer: Cigna of CA HMO |
$1.09
|
| Rate for Payer: Cigna of CA PPO |
$1.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.62
|
| Rate for Payer: EPIC Health Plan Senior |
$0.62
|
| Rate for Payer: Galaxy Health WC |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.40
|
| Rate for Payer: InnovAge PACE Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.09
|
| Rate for Payer: Multiplan Commercial |
$1.17
|
| Rate for Payer: Networks By Design Commercial |
$1.01
|
| Rate for Payer: Prime Health Services Commercial |
$1.33
|
| Rate for Payer: Riverside University Health System MISP |
$0.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO |
$0.78
|
| Rate for Payer: United Healthcare HMO Rider |
$0.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1.33
|
|
|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 002
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 001
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$263,446.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 006
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$263,446.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 005
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$263,446.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$263,446.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$263,446.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.14
|
| Rate for Payer: Blue Shield of California Commercial |
$21.85
|
| Rate for Payer: Blue Shield of California EPN |
$14.29
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Central Health Plan Commercial |
$28.80
|
| Rate for Payer: Cigna of CA HMO |
$23.04
|
| Rate for Payer: Cigna of CA PPO |
$26.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$51.60
|
| Rate for Payer: InnovAge PACE Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: Riverside University Health System MISP |
$14.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$32.40 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$27.83
|
| Rate for Payer: Blue Shield of California EPN |
$18.14
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Central Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$32.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$35.85 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.16
|
| Rate for Payer: Blue Shield of California Commercial |
$9.47
|
| Rate for Payer: Blue Shield of California EPN |
$6.19
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: Cigna of CA HMO |
$9.98
|
| Rate for Payer: Cigna of CA PPO |
$11.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Senior |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$32.46
|
| Rate for Payer: InnovAge PACE Commercial |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: Riverside University Health System MISP |
$6.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$14.04 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California Commercial |
$12.06
|
| Rate for Payer: Blue Shield of California EPN |
$7.86
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Central Health Plan Commercial |
$12.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Senior |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$14.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.11
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
IP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.78 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.26
|
| Rate for Payer: Blue Shield of California EPN |
$6.04
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Central Health Plan Commercial |
$9.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: EPIC Health Plan Senior |
$4.79
|
| Rate for Payer: Galaxy Health WC |
$10.18
|
| Rate for Payer: Global Benefits Group Commercial |
$7.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.79
|
| Rate for Payer: Prime Health Services Commercial |
$10.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.92
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
OP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$80.86 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.04
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.76
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Central Health Plan Commercial |
$9.58
|
| Rate for Payer: Cigna of CA HMO |
$7.67
|
| Rate for Payer: Cigna of CA PPO |
$8.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: EPIC Health Plan Senior |
$4.79
|
| Rate for Payer: Galaxy Health WC |
$10.18
|
| Rate for Payer: Global Benefits Group Commercial |
$7.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$73.20
|
| Rate for Payer: InnovAge PACE Commercial |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.39
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: Networks By Design Commercial |
$7.79
|
| Rate for Payer: Prime Health Services Commercial |
$10.18
|
| Rate for Payer: Riverside University Health System MISP |
$4.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.18
|
| Rate for Payer: Vantage Medical Group Senior |
$10.18
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
OP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$583.26 |
| Rate for Payer: Adventist Health Commercial |
$99.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$423.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$241.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$292.93
|
| Rate for Payer: Blue Shield of California Commercial |
$302.75
|
| Rate for Payer: Blue Shield of California EPN |
$198.01
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Central Health Plan Commercial |
$399.02
|
| Rate for Payer: Cigna of CA HMO |
$319.21
|
| Rate for Payer: Cigna of CA PPO |
$369.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$423.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$423.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$423.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.51
|
| Rate for Payer: EPIC Health Plan Senior |
$199.51
|
| Rate for Payer: Galaxy Health WC |
$423.95
|
| Rate for Payer: Global Benefits Group Commercial |
$299.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$448.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$528.01
|
| Rate for Payer: InnovAge PACE Commercial |
$249.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$583.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$308.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.14
|
| Rate for Payer: Multiplan Commercial |
$374.08
|
| Rate for Payer: Networks By Design Commercial |
$324.20
|
| Rate for Payer: Prime Health Services Commercial |
$423.95
|
| Rate for Payer: Riverside University Health System MISP |
$199.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$187.19
|
| Rate for Payer: United Healthcare All Other HMO |
$182.20
|
| Rate for Payer: United Healthcare HMO Rider |
$178.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$163.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$423.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$423.95
|
| Rate for Payer: Vantage Medical Group Senior |
$423.95
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
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Facility
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IP
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$498.77
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Service Code
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HCPCS A9562
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| Hospital Charge Code |
901700057
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Hospital Revenue Code
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343
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| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$448.89 |
| Rate for Payer: Adventist Health Commercial |
$99.75
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| Rate for Payer: Blue Shield of California Commercial |
$385.55
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| Rate for Payer: Blue Shield of California EPN |
$251.38
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| Rate for Payer: Cash Price |
$274.32
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| Rate for Payer: Central Health Plan Commercial |
$399.02
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| Rate for Payer: EPIC Health Plan Commercial |
$199.51
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| Rate for Payer: EPIC Health Plan Senior |
$199.51
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| Rate for Payer: Galaxy Health WC |
$423.95
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| Rate for Payer: Global Benefits Group Commercial |
$299.26
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| Rate for Payer: Health Management Network EPO/PPO |
$448.89
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| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.68
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| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.03
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| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$308.74
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| Rate for Payer: LLUH Dept of Risk Management WC |
$99.75
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| Rate for Payer: Multiplan Commercial |
$374.08
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| Rate for Payer: Networks By Design Commercial |
$324.20
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| Rate for Payer: Prime Health Services Commercial |
$423.95
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| Rate for Payer: United Healthcare All Other Commercial |
$187.19
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| Rate for Payer: United Healthcare All Other HMO |
$182.20
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| Rate for Payer: United Healthcare HMO Rider |
$178.26
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| Rate for Payer: United Healthcare Select/Navigate/Core |
$163.35
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