|
Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 28120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,044.21 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,044.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$4,044.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,632.50
|
| Rate for Payer: IEHP medi-cal |
$6,672.95
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Innovage PACE Commercial |
$6,066.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,419.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Prime Health Services Medicare |
$4,286.86
|
| Rate for Payer: Riverside University Health MISP |
$4,448.63
|
| 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 |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Partial hymenectomy or revision of hymenal ring
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 56700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,906.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| 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 |
$3,906.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,273.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,906.18
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,406.14
|
| Rate for Payer: IEHP medi-cal |
$6,445.20
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Innovage PACE Commercial |
$5,859.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,906.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,234.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,234.28
|
| Rate for Payer: Prime Health Services Medicare |
$4,140.55
|
| Rate for Payer: Riverside University Health MISP |
$4,296.80
|
| 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 |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$27,613.56
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$23,172.22 |
| Max. Negotiated Rate |
$27,613.56 |
| Rate for Payer: Adventist Health Medi-Cal |
$23,172.22
|
| Rate for Payer: IEHP medi-cal |
$27,613.56
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$6,956.78
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$5,837.86 |
| Max. Negotiated Rate |
$6,956.78 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,837.86
|
| Rate for Payer: IEHP medi-cal |
$6,956.78
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$11,956.80
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$10,033.68 |
| Max. Negotiated Rate |
$11,956.80 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,033.68
|
| Rate for Payer: IEHP medi-cal |
$11,956.80
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
IP
|
$4,293.93
|
|
|
Service Code
|
APR-DRG 8441
|
| Min. Negotiated Rate |
$3,603.30 |
| Max. Negotiated Rate |
$4,293.93 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,603.30
|
| Rate for Payer: IEHP medi-cal |
$4,293.93
|
|
|
Partial thyroid lobectomy, unilateral; with or without isthmusectomy
|
Facility
OP
|
$27,445.00
|
|
|
Service Code
|
CPT 60210
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,736.00 |
| Max. Negotiated Rate |
$27,445.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,209.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,209.21
|
| 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 |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$7,209.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,813.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,732.43
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,209.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,209.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,823.10
|
| Rate for Payer: IEHP medi-cal |
$11,895.20
|
| Rate for Payer: IEHP Medicare Advantage |
$7,209.21
|
| Rate for Payer: Innovage PACE Commercial |
$10,813.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,209.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,660.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,660.34
|
| Rate for Payer: Prime Health Services Medicare |
$7,641.76
|
| Rate for Payer: Riverside University Health MISP |
$7,930.13
|
| 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 |
$10,813.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: Vantage Medical Group Senior |
$7,209.21
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Blue Shield of California Commercial |
$29.70
|
| Rate for Payer: Blue Shield of California EPN |
$21.15
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-30
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.40
|
| Rate for Payer: BCBS Transplant Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.91
|
| Rate for Payer: Blue Shield of California EPN |
$19.36
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.70
|
| Rate for Payer: IEHP medi-cal |
$13.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: Riverside University Health MISP |
$15.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.40
|
| Rate for Payer: BCBS Transplant Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.91
|
| Rate for Payer: Blue Shield of California EPN |
$19.36
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.70
|
| Rate for Payer: IEHP medi-cal |
$13.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: Riverside University Health MISP |
$15.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 16.8 GRAM ORAL POWDER PACKET [211786]
|
Facility
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-168-01
|
| Hospital Charge Code |
ERX211786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Blue Shield of California Commercial |
$29.70
|
| Rate for Payer: Blue Shield of California EPN |
$21.15
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.40
|
| Rate for Payer: BCBS Transplant Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.91
|
| Rate for Payer: Blue Shield of California EPN |
$19.36
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.70
|
| Rate for Payer: IEHP medi-cal |
$13.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: Riverside University Health MISP |
$15.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Blue Shield of California Commercial |
$29.70
|
| Rate for Payer: Blue Shield of California EPN |
$21.15
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
IP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-01
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Blue Shield of California Commercial |
$29.70
|
| Rate for Payer: Blue Shield of California EPN |
$21.15
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
|
|
PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]
|
Facility
OP
|
$39.60
|
|
|
Service Code
|
NDC 53436-084-30
|
| Hospital Charge Code |
ERX211785
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$35.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.40
|
| Rate for Payer: BCBS Transplant Transplant |
$23.76
|
| Rate for Payer: Blue Shield of California Commercial |
$24.91
|
| Rate for Payer: Blue Shield of California EPN |
$19.36
|
| Rate for Payer: Cash Price |
$17.82
|
| Rate for Payer: Central Health Plan Commercial |
$31.68
|
| Rate for Payer: Cigna of CA HMO |
$27.72
|
| Rate for Payer: Cigna of CA PPO |
$27.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.84
|
| Rate for Payer: Galaxy Health WC |
$33.66
|
| Rate for Payer: Global Benefits Group Commercial |
$23.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.70
|
| Rate for Payer: IEHP medi-cal |
$13.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.92
|
| Rate for Payer: Multiplan Commercial |
$29.70
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$33.66
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: Riverside University Health MISP |
$15.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO |
$19.80
|
| Rate for Payer: United Healthcare HMO Rider |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.66
|
| Rate for Payer: Vantage Medical Group Senior |
$33.66
|
|
|
Pediatric Heart Transplant
|
Facility
IP
|
$282,540.00
|
|
|
Service Code
|
MS-DRG 002
|
| Min. Negotiated Rate |
$185,000.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: BCBS Transplant Transplant |
$282,540.00
|
| Rate for Payer: OptumHealth/URN Transplant Commercial |
$185,000.00
|
|
|
Pediatric Heart Transplant
|
Facility
IP
|
$282,540.00
|
|
|
Service Code
|
MS-DRG 001
|
| Min. Negotiated Rate |
$185,000.00 |
| Max. Negotiated Rate |
$282,540.00 |
| Rate for Payer: BCBS Transplant Transplant |
$282,540.00
|
| Rate for Payer: OptumHealth/URN Transplant Commercial |
$185,000.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 652
|
| Min. Negotiated Rate |
$80,000.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant Transplant |
$113,455.00
|
| Rate for Payer: OptumHealth/URN Transplant Commercial |
$80,000.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 650
|
| Min. Negotiated Rate |
$80,000.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant Transplant |
$113,455.00
|
| Rate for Payer: OptumHealth/URN Transplant Commercial |
$80,000.00
|
|
|
Pediatric Kidney Transplant
|
Facility
IP
|
$113,455.00
|
|
|
Service Code
|
MS-DRG 651
|
| Min. Negotiated Rate |
$80,000.00 |
| Max. Negotiated Rate |
$113,455.00 |
| Rate for Payer: BCBS Transplant Transplant |
$113,455.00
|
| Rate for Payer: OptumHealth/URN Transplant Commercial |
$80,000.00
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 87040203
|
| Hospital Charge Code |
1715260
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 87040203
|
| Hospital Charge Code |
1715260
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: BCBS Transplant Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.15
|
| Rate for Payer: IEHP medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
PEDIATRIC MULTIVITAMIN NO.40-PHYTONADIONE 400 MCG/ML ORAL DROPS [118399]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 5891421460
|
| Hospital Charge Code |
NDG118399
|
|
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
|
|
|
PEDIATRIC MULTIVITAMIN NO.40-PHYTONADIONE 400 MCG/ML ORAL DROPS [118399]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 5891421460
|
| Hospital Charge Code |
NDG118399
|
|
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
|
|
|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
OP
|
$0.66
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
ERX206186
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.53
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: IEHP medi-cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: Riverside University Health MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
