|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 0054-0021-25
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
| Rate for Payer: IEHP medi-cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: Riverside University Health MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 0054-0021-25
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 51079-180-20
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| 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 |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 68084-640-11
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084-640-11
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.33
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Riverside University Health MISP |
$0.18
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 51079-180-20
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Riverside University Health MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 68084-640-01
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE [10454]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084-640-01
|
| Hospital Charge Code |
1710490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.33
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Riverside University Health MISP |
$0.18
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 52318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm)
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Lithotripsy, extracorporeal shock wave
|
Facility
OP
|
$27,445.00
|
|
|
Service Code
|
CPT 50590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,355.72 |
| Max. Negotiated Rate |
$27,445.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$26,109.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11,461.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,979.00
|
| Rate for Payer: Blue Shield of California Commercial |
$12,373.72
|
| Rate for Payer: Blue Shield of California EPN |
$8,887.36
|
| Rate for Payer: Caremore Medicare Advantage |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,813.00
|
| Rate for Payer: United Healthcare All Other HMO |
$27,445.00
|
| Rate for Payer: United Healthcare HMO Rider |
$17,214.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,742.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Liver-Pancreas Transplant
|
Facility
IP
|
$207,500.00
|
|
|
Service Code
|
MS-DRG 010
|
| Min. Negotiated Rate |
$207,500.00 |
| Max. Negotiated Rate |
$207,500.00 |
| Rate for Payer: Blue Shield of California Transplant |
$207,500.00
|
|
|
Liver-Pancreas Transplant
|
Facility
IP
|
$207,500.00
|
|
|
Service Code
|
MS-DRG 005
|
| Min. Negotiated Rate |
$207,500.00 |
| Max. Negotiated Rate |
$207,500.00 |
| Rate for Payer: Blue Shield of California Transplant |
$207,500.00
|
|
|
Liver-Pancreas Transplant
|
Facility
IP
|
$207,500.00
|
|
|
Service Code
|
MS-DRG 006
|
| Min. Negotiated Rate |
$207,500.00 |
| Max. Negotiated Rate |
$207,500.00 |
| Rate for Payer: Blue Shield of California Transplant |
$207,500.00
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
IP
|
$174,043.63
|
|
|
Service Code
|
APR-DRG 0014
|
| Min. Negotiated Rate |
$146,050.60 |
| Max. Negotiated Rate |
$174,043.63 |
| Rate for Payer: Adventist Health Medi-Cal |
$146,050.60
|
| Rate for Payer: IEHP medi-cal |
$174,043.63
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
IP
|
$74,874.81
|
|
|
Service Code
|
APR-DRG 0011
|
| Min. Negotiated Rate |
$62,832.01 |
| Max. Negotiated Rate |
$74,874.81 |
| Rate for Payer: Adventist Health Medi-Cal |
$62,832.01
|
| Rate for Payer: IEHP medi-cal |
$74,874.81
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
IP
|
$100,619.70
|
|
|
Service Code
|
APR-DRG 0013
|
| Min. Negotiated Rate |
$84,436.12 |
| Max. Negotiated Rate |
$100,619.70 |
| Rate for Payer: Adventist Health Medi-Cal |
$84,436.12
|
| Rate for Payer: IEHP medi-cal |
$100,619.70
|
|
|
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT
|
Facility
IP
|
$84,331.60
|
|
|
Service Code
|
APR-DRG 0012
|
| Min. Negotiated Rate |
$70,767.78 |
| Max. Negotiated Rate |
$84,331.60 |
| Rate for Payer: Adventist Health Medi-Cal |
$70,767.78
|
| Rate for Payer: IEHP medi-cal |
$84,331.60
|
|
|
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION [231219]
|
Facility
IP
|
$30,640.79
|
|
|
Service Code
|
NDC 79952-110-01
|
| Hospital Charge Code |
ERX231219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,128.16 |
| Max. Negotiated Rate |
$27,576.71 |
| Rate for Payer: Blue Shield of California Commercial |
$22,980.59
|
| Rate for Payer: Blue Shield of California EPN |
$16,362.18
|
| Rate for Payer: Cash Price |
$13,788.36
|
| Rate for Payer: Central Health Plan Commercial |
$24,512.63
|
| Rate for Payer: Cigna of CA HMO |
$21,448.55
|
| Rate for Payer: Cigna of CA PPO |
$21,448.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,256.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$12,256.32
|
| Rate for Payer: Galaxy Health WC |
$26,044.67
|
| Rate for Payer: Global Benefits Group Commercial |
$18,384.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$27,576.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20,437.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,128.16
|
| Rate for Payer: Multiplan Commercial |
$22,980.59
|
| Rate for Payer: Networks By Design Commercial |
$15,320.40
|
| Rate for Payer: Prime Health Services Commercial |
$26,044.67
|
|
|
LONCASTUXIMAB TESIRINE-LPYL 10 MG INTRAVENOUS SOLUTION [231219]
|
Facility
OP
|
$30,640.79
|
|
|
Service Code
|
NDC 79952-110-01
|
| Hospital Charge Code |
ERX231219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,128.16 |
| Max. Negotiated Rate |
$27,576.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$18,608.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26,044.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16,852.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16,852.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14,836.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18,102.58
|
| Rate for Payer: BCBS Transplant Transplant |
$18,384.47
|
| Rate for Payer: Blue Shield of California Commercial |
$19,273.06
|
| Rate for Payer: Blue Shield of California EPN |
$14,983.35
|
| Rate for Payer: Cash Price |
$13,788.36
|
| Rate for Payer: Cash Price |
$13,788.36
|
| Rate for Payer: Central Health Plan Commercial |
$24,512.63
|
| Rate for Payer: Cigna of CA HMO |
$21,448.55
|
| Rate for Payer: Cigna of CA PPO |
$21,448.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26,044.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,256.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$12,256.32
|
| Rate for Payer: Galaxy Health WC |
$26,044.67
|
| Rate for Payer: Global Benefits Group Commercial |
$18,384.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$27,576.71
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$22,980.59
|
| Rate for Payer: IEHP medi-cal |
$10,724.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$20,437.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,128.16
|
| Rate for Payer: Multiplan Commercial |
$22,980.59
|
| Rate for Payer: Networks By Design Commercial |
$15,320.40
|
| Rate for Payer: Prime Health Services Commercial |
$26,044.67
|
| Rate for Payer: Riverside University Health MISP |
$12,256.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18,384.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18,384.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$15,320.40
|
| Rate for Payer: United Healthcare All Other HMO |
$15,320.40
|
| Rate for Payer: United Healthcare HMO Rider |
$15,320.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,320.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26,044.67
|
| Rate for Payer: Vantage Medical Group Senior |
$26,044.67
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
NDG42219
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID [42219]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 0904-6836-20
|
| Hospital Charge Code |
NDG42219
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
OP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.33
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Riverside University Health MISP |
$0.18
|
| 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 Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
IP
|
$0.44
|
|
|
Service Code
|
NDC 0093-0311-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.31
|
| Rate for Payer: Cigna of CA PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| 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 |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
LOPERAMIDE 2 MG CAPSULE [4560]
|
Facility
IP
|
$0.87
|
|
|
Service Code
|
NDC 51079-690-01
|
| Hospital Charge Code |
1710333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Central Health Plan Commercial |
$0.70
|
| Rate for Payer: Cigna of CA HMO |
$0.61
|
| Rate for Payer: Cigna of CA PPO |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.74
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.74
|
|
