|
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 52500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$725.53 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,533.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,800.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,987.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,533.71
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$6,982.34
|
| Rate for Payer: Blue Shield of California Commercial |
$5,036.70
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,800.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,987.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,533.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,480.62
|
| Rate for Payer: EPIC Health Plan Senior |
$4,987.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,435.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$725.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,533.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$801.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,347.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,075.17
|
| Rate for Payer: Multiplan WC |
$6,982.34
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,533.71
|
| Rate for Payer: Preferred Health Network WC |
$7,124.84
|
| Rate for Payer: Prime Health Services Medicare |
$4,805.73
|
| Rate for Payer: Prime Health Services WC |
$6,911.09
|
| Rate for Payer: Riverside University Health System MISP |
$4,987.08
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,533.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,800.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,987.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4,533.71
|
|
|
TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 52630
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,165.61 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,896.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,344.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,585.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,896.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,291.67
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,344.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,585.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,896.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,378.68
|
| Rate for Payer: EPIC Health Plan Senior |
$7,585.79
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,309.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,896.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,654.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9,240.87
|
| Rate for Payer: Multiplan WC |
$10,291.67
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$6,896.17
|
| Rate for Payer: Preferred Health Network WC |
$10,501.70
|
| Rate for Payer: Prime Health Services Medicare |
$7,309.94
|
| Rate for Payer: Prime Health Services WC |
$10,186.65
|
| Rate for Payer: Riverside University Health System MISP |
$7,585.79
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$6,896.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,344.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,585.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6,896.17
|
|
|
TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 64488
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 64486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
|
IP
|
$1,870.10
|
|
|
Service Code
|
HCPCS J9355
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$374.02 |
| Max. Negotiated Rate |
$1,683.09 |
| Rate for Payer: Adventist Health Commercial |
$374.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1,499.82
|
| Rate for Payer: Blue Shield of California EPN |
$942.53
|
| Rate for Payer: Cash Price |
$841.54
|
| Rate for Payer: Central Health Plan Commercial |
$1,496.08
|
| Rate for Payer: Cigna of CA HMO |
$1,309.07
|
| Rate for Payer: Cigna of CA PPO |
$1,309.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,309.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$748.04
|
| Rate for Payer: EPIC Health Plan Senior |
$748.04
|
| Rate for Payer: Galaxy Health WC |
$1,589.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1,122.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,683.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,187.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,103.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$374.02
|
| Rate for Payer: Multiplan Commercial |
$1,402.58
|
| Rate for Payer: Networks By Design Commercial |
$935.05
|
| Rate for Payer: Prime Health Services Commercial |
$1,589.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$701.85
|
| Rate for Payer: United Healthcare All Other HMO |
$683.15
|
| Rate for Payer: United Healthcare HMO Rider |
$668.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$612.46
|
|
|
TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION [216113]
|
Facility
|
OP
|
$1,870.10
|
|
|
Service Code
|
HCPCS J9355
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.24 |
| Max. Negotiated Rate |
$1,683.09 |
| Rate for Payer: Adventist Health Commercial |
$374.02
|
| Rate for Payer: Adventist Health Medi-Cal |
$70.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$469.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$105.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$77.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$70.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$99.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$123.58
|
| Rate for Payer: Blue Shield of California Commercial |
$137.14
|
| Rate for Payer: Blue Shield of California EPN |
$124.67
|
| Rate for Payer: Cash Price |
$841.54
|
| Rate for Payer: Cash Price |
$841.54
|
| Rate for Payer: Central Health Plan Commercial |
$1,496.08
|
| Rate for Payer: Cigna of CA HMO |
$1,309.07
|
| Rate for Payer: Cigna of CA PPO |
$1,309.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$77.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$77.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,309.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.90
|
| Rate for Payer: EPIC Health Plan Senior |
$77.26
|
| Rate for Payer: Galaxy Health WC |
$1,589.59
|
| Rate for Payer: Global Benefits Group Commercial |
$1,122.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,683.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$115.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$70.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$70.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,187.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$139.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$98.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$374.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$94.12
|
| Rate for Payer: Multiplan Commercial |
$1,402.58
|
| Rate for Payer: Networks By Design Commercial |
$935.05
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$70.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,589.59
|
| Rate for Payer: Prime Health Services Medicare |
$74.45
|
| Rate for Payer: Riverside University Health System MISP |
$77.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,122.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,122.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$701.85
|
| Rate for Payer: United Healthcare All Other HMO |
$683.15
|
| Rate for Payer: United Healthcare HMO Rider |
$668.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$612.46
|
| Rate for Payer: Upland Medical Group Pediatric |
$70.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$87.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$77.26
|
| Rate for Payer: Vantage Medical Group Senior |
$77.26
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
|
OP
|
$1,122.06
|
|
|
Service Code
|
HCPCS J9356
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.34 |
| Max. Negotiated Rate |
$1,009.85 |
| Rate for Payer: Adventist Health Commercial |
$224.41
|
| Rate for Payer: Adventist Health Medi-Cal |
$58.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$389.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$58.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$154.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$192.43
|
| Rate for Payer: Blue Shield of California Commercial |
$102.85
|
| Rate for Payer: Blue Shield of California EPN |
$93.50
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Central Health Plan Commercial |
$897.65
|
| Rate for Payer: Cigna of CA HMO |
$785.44
|
| Rate for Payer: Cigna of CA PPO |
$785.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$785.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.26
|
| Rate for Payer: EPIC Health Plan Senior |
$64.17
|
| Rate for Payer: Galaxy Health WC |
$953.75
|
| Rate for Payer: Global Benefits Group Commercial |
$673.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,009.85
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$95.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$58.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$58.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$712.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$124.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$81.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.18
|
| Rate for Payer: Multiplan Commercial |
$841.54
|
| Rate for Payer: Networks By Design Commercial |
$561.03
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$58.34
|
| Rate for Payer: Prime Health Services Commercial |
$953.75
|
| Rate for Payer: Prime Health Services Medicare |
$61.84
|
| Rate for Payer: Riverside University Health System MISP |
$64.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$673.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$673.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.11
|
| Rate for Payer: United Healthcare All Other HMO |
$409.89
|
| Rate for Payer: United Healthcare HMO Rider |
$401.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.47
|
| Rate for Payer: Upland Medical Group Pediatric |
$58.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.17
|
| Rate for Payer: Vantage Medical Group Senior |
$64.17
|
|
|
TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION [224561]
|
Facility
|
IP
|
$1,122.06
|
|
|
Service Code
|
HCPCS J9356
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$224.41 |
| Max. Negotiated Rate |
$1,009.85 |
| Rate for Payer: Adventist Health Commercial |
$224.41
|
| Rate for Payer: Blue Shield of California Commercial |
$899.89
|
| Rate for Payer: Blue Shield of California EPN |
$565.52
|
| Rate for Payer: Cash Price |
$504.93
|
| Rate for Payer: Central Health Plan Commercial |
$897.65
|
| Rate for Payer: Cigna of CA HMO |
$785.44
|
| Rate for Payer: Cigna of CA PPO |
$785.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$785.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$448.82
|
| Rate for Payer: EPIC Health Plan Senior |
$448.82
|
| Rate for Payer: Galaxy Health WC |
$953.75
|
| Rate for Payer: Global Benefits Group Commercial |
$673.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,009.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$712.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$662.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.41
|
| Rate for Payer: Multiplan Commercial |
$841.54
|
| Rate for Payer: Networks By Design Commercial |
$561.03
|
| Rate for Payer: Prime Health Services Commercial |
$953.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.11
|
| Rate for Payer: United Healthcare All Other HMO |
$409.89
|
| Rate for Payer: United Healthcare HMO Rider |
$401.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$367.47
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
|
IP
|
$1,632.08
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$326.42 |
| Max. Negotiated Rate |
$1,468.87 |
| Rate for Payer: Adventist Health Commercial |
$326.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1,308.93
|
| Rate for Payer: Blue Shield of California EPN |
$822.57
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Central Health Plan Commercial |
$1,305.66
|
| Rate for Payer: Cigna of CA HMO |
$1,142.46
|
| Rate for Payer: Cigna of CA PPO |
$1,142.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,142.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$652.83
|
| Rate for Payer: EPIC Health Plan Senior |
$652.83
|
| Rate for Payer: Galaxy Health WC |
$1,387.27
|
| Rate for Payer: Global Benefits Group Commercial |
$979.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,468.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,036.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$962.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$326.42
|
| Rate for Payer: Multiplan Commercial |
$1,224.06
|
| Rate for Payer: Networks By Design Commercial |
$816.04
|
| Rate for Payer: Prime Health Services Commercial |
$1,387.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$612.52
|
| Rate for Payer: United Healthcare All Other HMO |
$596.20
|
| Rate for Payer: United Healthcare HMO Rider |
$583.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$534.51
|
|
|
TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION [226189]
|
Facility
|
OP
|
$1,632.08
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.52 |
| Max. Negotiated Rate |
$1,468.87 |
| Rate for Payer: Adventist Health Commercial |
$326.42
|
| Rate for Payer: Adventist Health Medi-Cal |
$60.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$172.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$174.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$217.43
|
| Rate for Payer: Blue Shield of California Commercial |
$119.69
|
| Rate for Payer: Blue Shield of California EPN |
$108.81
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Cash Price |
$734.44
|
| Rate for Payer: Central Health Plan Commercial |
$1,305.66
|
| Rate for Payer: Cigna of CA HMO |
$1,142.46
|
| Rate for Payer: Cigna of CA PPO |
$1,142.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$75.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$66.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,142.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.86
|
| Rate for Payer: EPIC Health Plan Senior |
$66.57
|
| Rate for Payer: Galaxy Health WC |
$1,387.27
|
| Rate for Payer: Global Benefits Group Commercial |
$979.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,468.87
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$99.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$60.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,036.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$326.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$81.10
|
| Rate for Payer: Multiplan Commercial |
$1,224.06
|
| Rate for Payer: Networks By Design Commercial |
$816.04
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$60.52
|
| Rate for Payer: Prime Health Services Commercial |
$1,387.27
|
| Rate for Payer: Prime Health Services Medicare |
$64.15
|
| Rate for Payer: Riverside University Health System MISP |
$66.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$979.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$979.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$612.52
|
| Rate for Payer: United Healthcare All Other HMO |
$596.20
|
| Rate for Payer: United Healthcare HMO Rider |
$583.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$534.51
|
| Rate for Payer: Upland Medical Group Pediatric |
$60.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$75.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.57
|
| Rate for Payer: Vantage Medical Group Senior |
$66.57
|
|
|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
|
IP
|
$4,569.82
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$913.96 |
| Max. Negotiated Rate |
$4,112.84 |
| Rate for Payer: Adventist Health Commercial |
$913.96
|
| Rate for Payer: Blue Shield of California Commercial |
$3,665.00
|
| Rate for Payer: Blue Shield of California EPN |
$2,303.19
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Central Health Plan Commercial |
$3,655.86
|
| Rate for Payer: Cigna of CA HMO |
$3,198.87
|
| Rate for Payer: Cigna of CA PPO |
$3,198.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,198.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,827.93
|
| Rate for Payer: EPIC Health Plan Senior |
$1,827.93
|
| Rate for Payer: Galaxy Health WC |
$3,884.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2,741.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,112.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,901.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,696.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$913.96
|
| Rate for Payer: Multiplan Commercial |
$3,427.36
|
| Rate for Payer: Networks By Design Commercial |
$2,284.91
|
| Rate for Payer: Prime Health Services Commercial |
$3,884.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,715.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1,669.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1,633.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,496.62
|
|
|
TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION [225307]
|
Facility
|
OP
|
$4,569.82
|
|
|
Service Code
|
HCPCS Q5117
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.52 |
| Max. Negotiated Rate |
$4,112.84 |
| Rate for Payer: Adventist Health Commercial |
$913.96
|
| Rate for Payer: Adventist Health Medi-Cal |
$60.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$172.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$174.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$217.43
|
| Rate for Payer: Blue Shield of California Commercial |
$119.69
|
| Rate for Payer: Blue Shield of California EPN |
$108.81
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Cash Price |
$2,056.42
|
| Rate for Payer: Central Health Plan Commercial |
$3,655.86
|
| Rate for Payer: Cigna of CA HMO |
$3,198.87
|
| Rate for Payer: Cigna of CA PPO |
$3,198.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$75.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$66.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3,198.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.86
|
| Rate for Payer: EPIC Health Plan Senior |
$66.57
|
| Rate for Payer: Galaxy Health WC |
$3,884.35
|
| Rate for Payer: Global Benefits Group Commercial |
$2,741.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$4,112.84
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$99.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$60.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,901.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$97.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$913.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$81.10
|
| Rate for Payer: Multiplan Commercial |
$3,427.36
|
| Rate for Payer: Networks By Design Commercial |
$2,284.91
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$60.52
|
| Rate for Payer: Prime Health Services Commercial |
$3,884.35
|
| Rate for Payer: Prime Health Services Medicare |
$64.15
|
| Rate for Payer: Riverside University Health System MISP |
$66.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,741.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,741.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,715.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1,669.36
|
| Rate for Payer: United Healthcare HMO Rider |
$1,633.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,496.62
|
| Rate for Payer: Upland Medical Group Pediatric |
$60.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$75.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.57
|
| Rate for Payer: Vantage Medical Group Senior |
$66.57
|
|
|
TRAUMATIC INJURY WITH MCC
|
Facility
|
IP
|
$43,021.04
|
|
|
Service Code
|
MSDRG 913
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$43,021.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$43,021.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$27,789.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38,906.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$38,686.00
|
| Rate for Payer: EPIC Health Plan Senior |
$25,790.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23,446.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$32,824.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$31,417.72
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$23,446.06
|
| Rate for Payer: Prime Health Services Medicare |
$24,852.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC INJURY WITHOUT MCC
|
Facility
|
IP
|
$23,305.47
|
|
|
Service Code
|
MSDRG 914
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$23,305.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23,305.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15,054.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,076.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$21,638.88
|
| Rate for Payer: EPIC Health Plan Senior |
$14,425.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,114.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,360.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,573.39
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$13,114.47
|
| Rate for Payer: Prime Health Services Medicare |
$13,901.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC
|
Facility
|
IP
|
$34,285.76
|
|
|
Service Code
|
MSDRG 086
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$34,285.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$34,285.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22,147.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$31,006.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$31,133.04
|
| Rate for Payer: EPIC Health Plan Senior |
$20,755.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,868.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,415.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,283.80
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$18,868.51
|
| Rate for Payer: Prime Health Services Medicare |
$20,000.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC
|
Facility
|
IP
|
$36,736.06
|
|
|
Service Code
|
MSDRG 083
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$36,736.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$36,736.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$23,730.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33,222.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$33,251.69
|
| Rate for Payer: EPIC Health Plan Senior |
$22,167.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,152.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,213.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,004.40
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$20,152.54
|
| Rate for Payer: Prime Health Services Medicare |
$21,361.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC
|
Facility
|
IP
|
$59,794.14
|
|
|
Service Code
|
MSDRG 085
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$59,794.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$59,794.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$38,624.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54,075.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$53,189.00
|
| Rate for Payer: EPIC Health Plan Senior |
$35,459.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32,235.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$45,130.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43,195.92
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$32,235.76
|
| Rate for Payer: Prime Health Services Medicare |
$34,169.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC
|
Facility
|
IP
|
$60,154.71
|
|
|
Service Code
|
MSDRG 082
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$60,154.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$60,154.71
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$38,857.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54,401.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$53,500.74
|
| Rate for Payer: EPIC Health Plan Senior |
$35,667.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32,424.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$45,394.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43,449.08
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$32,424.69
|
| Rate for Payer: Prime Health Services Medicare |
$34,370.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC
|
Facility
|
IP
|
$24,073.99
|
|
|
Service Code
|
MSDRG 087
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$24,073.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24,073.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15,550.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,771.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,303.35
|
| Rate for Payer: EPIC Health Plan Senior |
$14,868.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,517.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,924.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,113.02
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$13,517.18
|
| Rate for Payer: Prime Health Services Medicare |
$14,328.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC
|
Facility
|
IP
|
$25,155.70
|
|
|
Service Code
|
MSDRG 084
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$25,155.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$25,155.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$16,249.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22,749.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$23,238.67
|
| Rate for Payer: EPIC Health Plan Senior |
$15,492.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,084.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,717.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,872.61
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$14,084.04
|
| Rate for Payer: Prime Health Services Medicare |
$14,929.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC
|
Facility
|
IP
|
$38,744.20
|
|
|
Service Code
|
MSDRG 604
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$38,744.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$38,744.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25,027.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35,038.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$34,988.07
|
| Rate for Payer: EPIC Health Plan Senior |
$23,325.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,204.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29,686.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,414.55
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$21,204.89
|
| Rate for Payer: Prime Health Services Medicare |
$22,477.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC
|
Facility
|
IP
|
$24,108.20
|
|
|
Service Code
|
MSDRG 605
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$24,108.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$24,108.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15,572.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,802.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,332.96
|
| Rate for Payer: EPIC Health Plan Senior |
$14,888.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,535.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,949.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,137.07
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$13,535.13
|
| Rate for Payer: Prime Health Services Medicare |
$14,347.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
IP
|
$60.36
|
|
|
Service Code
|
NDC 6050505934
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.07 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Adventist Health Commercial |
$12.07
|
| Rate for Payer: Blue Shield of California Commercial |
$48.41
|
| Rate for Payer: Blue Shield of California EPN |
$30.42
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Central Health Plan Commercial |
$48.29
|
| Rate for Payer: Cigna of CA HMO |
$42.25
|
| Rate for Payer: Cigna of CA PPO |
$42.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$42.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.14
|
| Rate for Payer: EPIC Health Plan Senior |
$24.14
|
| Rate for Payer: Galaxy Health WC |
$51.31
|
| Rate for Payer: Global Benefits Group Commercial |
$36.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$38.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$35.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.07
|
| Rate for Payer: Multiplan Commercial |
$45.27
|
| Rate for Payer: Networks By Design Commercial |
$39.23
|
| Rate for Payer: Prime Health Services Commercial |
$51.31
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
OP
|
$76.17
|
|
|
Service Code
|
NDC 0378965132
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$68.55 |
| Rate for Payer: Adventist Health Commercial |
$15.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$46.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$57.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$36.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.31
|
| Rate for Payer: Blue Shield of California Commercial |
$48.29
|
| Rate for Payer: Blue Shield of California EPN |
$30.39
|
| Rate for Payer: Cash Price |
$34.28
|
| Rate for Payer: Central Health Plan Commercial |
$60.94
|
| Rate for Payer: Cigna of CA HMO |
$53.32
|
| Rate for Payer: Cigna of CA PPO |
$53.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.74
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$53.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.47
|
| Rate for Payer: EPIC Health Plan Senior |
$30.47
|
| Rate for Payer: Galaxy Health WC |
$64.74
|
| Rate for Payer: Global Benefits Group Commercial |
$45.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$68.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$48.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$44.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$53.32
|
| Rate for Payer: Multiplan Commercial |
$57.13
|
| Rate for Payer: Networks By Design Commercial |
$49.51
|
| Rate for Payer: Prime Health Services Commercial |
$64.74
|
| Rate for Payer: Riverside University Health System MISP |
$30.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$45.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$45.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.09
|
| Rate for Payer: United Healthcare All Other HMO |
$38.09
|
| Rate for Payer: United Healthcare HMO Rider |
$38.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.74
|
| Rate for Payer: Vantage Medical Group Senior |
$64.74
|
|
|
TRAVOPROST 0.004 % EYE DROPS [110762]
|
Facility
|
OP
|
$60.36
|
|
|
Service Code
|
NDC 6050505934
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.07 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Adventist Health Commercial |
$12.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.11
|
| Rate for Payer: Blue Shield of California Commercial |
$38.27
|
| Rate for Payer: Blue Shield of California EPN |
$24.08
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Central Health Plan Commercial |
$48.29
|
| Rate for Payer: Cigna of CA HMO |
$42.25
|
| Rate for Payer: Cigna of CA PPO |
$42.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$42.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.14
|
| Rate for Payer: EPIC Health Plan Senior |
$24.14
|
| Rate for Payer: Galaxy Health WC |
$51.31
|
| Rate for Payer: Global Benefits Group Commercial |
$36.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$38.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$35.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.25
|
| Rate for Payer: Multiplan Commercial |
$45.27
|
| Rate for Payer: Networks By Design Commercial |
$39.23
|
| Rate for Payer: Prime Health Services Commercial |
$51.31
|
| Rate for Payer: Riverside University Health System MISP |
$24.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.18
|
| Rate for Payer: United Healthcare All Other HMO |
$30.18
|
| Rate for Payer: United Healthcare HMO Rider |
$30.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.31
|
| Rate for Payer: Vantage Medical Group Senior |
$51.31
|
|
