|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 7071014831
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 6068710001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$5.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Central Health Plan Commercial |
$5.71
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Senior |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$0.95
|
|
|
Service Code
|
NDC 5965142101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Central Health Plan Commercial |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$0.67
|
| Rate for Payer: Cigna of CA PPO |
$0.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Senior |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.81
|
| Rate for Payer: Global Benefits Group Commercial |
$0.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.62
|
| Rate for Payer: Prime Health Services Commercial |
$0.81
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 0527132601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.23
|
|
|
Service Code
|
NDC 0591315901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.86
|
| Rate for Payer: Cigna of CA PPO |
$0.86
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 6068710001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.15
|
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.85
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Central Health Plan Commercial |
$5.71
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Senior |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
| Rate for Payer: Riverside University Health System MISP |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.57
|
| Rate for Payer: United Healthcare All Other HMO |
$3.57
|
| Rate for Payer: United Healthcare HMO Rider |
$3.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.07
|
| Rate for Payer: Vantage Medical Group Senior |
$6.07
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 4280650301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 6068710011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$5.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$3.21
|
| Rate for Payer: Central Health Plan Commercial |
$5.71
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Senior |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.07
|
| Rate for Payer: Global Benefits Group Commercial |
$4.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Networks By Design Commercial |
$4.64
|
| Rate for Payer: Prime Health Services Commercial |
$6.07
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994080354
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.27
|
| Rate for Payer: Riverside University Health System MISP |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 66990
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$80.05 |
| 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 |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$80.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$88.43
|
| 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
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
IP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$92.45 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Blue Shield of California Commercial |
$82.38
|
| Rate for Payer: Blue Shield of California EPN |
$51.77
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Central Health Plan Commercial |
$82.18
|
| Rate for Payer: Cigna of CA HMO |
$71.90
|
| Rate for Payer: Cigna of CA PPO |
$71.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.09
|
| Rate for Payer: EPIC Health Plan Senior |
$41.09
|
| Rate for Payer: Galaxy Health WC |
$87.31
|
| Rate for Payer: Global Benefits Group Commercial |
$61.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$92.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$65.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Multiplan Commercial |
$77.04
|
| Rate for Payer: Networks By Design Commercial |
$51.36
|
| Rate for Payer: Prime Health Services Commercial |
$87.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.55
|
| Rate for Payer: United Healthcare All Other HMO |
$37.52
|
| Rate for Payer: United Healthcare HMO Rider |
$36.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.64
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
OP
|
$102.72
|
|
|
Service Code
|
HCPCS J3358
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.36 |
| Max. Negotiated Rate |
$92.45 |
| Rate for Payer: Adventist Health Commercial |
$20.54
|
| Rate for Payer: Adventist Health Medi-Cal |
$11.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$79.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.41
|
| Rate for Payer: Blue Shield of California Commercial |
$20.56
|
| Rate for Payer: Blue Shield of California EPN |
$18.69
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Cash Price |
$46.22
|
| Rate for Payer: Central Health Plan Commercial |
$82.18
|
| Rate for Payer: Cigna of CA HMO |
$71.90
|
| Rate for Payer: Cigna of CA PPO |
$71.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.74
|
| Rate for Payer: EPIC Health Plan Senior |
$12.50
|
| Rate for Payer: Galaxy Health WC |
$87.31
|
| Rate for Payer: Global Benefits Group Commercial |
$61.63
|
| Rate for Payer: Health Management Network EPO/PPO |
$92.45
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$65.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.22
|
| Rate for Payer: Multiplan Commercial |
$77.04
|
| Rate for Payer: Networks By Design Commercial |
$51.36
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$11.36
|
| Rate for Payer: Prime Health Services Commercial |
$87.31
|
| Rate for Payer: Prime Health Services Medicare |
$12.04
|
| Rate for Payer: Riverside University Health System MISP |
$12.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$61.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$61.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$38.55
|
| Rate for Payer: United Healthcare All Other HMO |
$37.52
|
| Rate for Payer: United Healthcare HMO Rider |
$36.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.64
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.50
|
| Rate for Payer: Vantage Medical Group Senior |
$12.50
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
OP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$215.12 |
| Max. Negotiated Rate |
$33,057.76 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,979.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20,201.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27,548.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$215.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$268.45
|
| Rate for Payer: Blue Shield of California Commercial |
$408.36
|
| Rate for Payer: Blue Shield of California EPN |
$371.24
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Central Health Plan Commercial |
$29,384.67
|
| Rate for Payer: Cigna of CA HMO |
$25,711.59
|
| Rate for Payer: Cigna of CA PPO |
$25,711.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$31,221.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31,221.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,692.34
|
| Rate for Payer: EPIC Health Plan Senior |
$14,692.34
|
| Rate for Payer: Galaxy Health WC |
$31,221.21
|
| Rate for Payer: Global Benefits Group Commercial |
$22,038.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$33,057.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$549.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,324.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$607.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,671.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,346.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,711.59
|
| Rate for Payer: Multiplan Commercial |
$27,548.13
|
| Rate for Payer: Networks By Design Commercial |
$18,365.42
|
| Rate for Payer: Prime Health Services Commercial |
$31,221.21
|
| Rate for Payer: Riverside University Health System MISP |
$14,692.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22,038.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22,038.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,785.08
|
| Rate for Payer: United Healthcare All Other HMO |
$13,417.78
|
| Rate for Payer: United Healthcare HMO Rider |
$13,127.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,029.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31,221.21
|
| Rate for Payer: Vantage Medical Group Senior |
$31,221.21
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
IP
|
$36,730.84
|
|
|
Service Code
|
HCPCS J3357
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,346.17 |
| Max. Negotiated Rate |
$33,057.76 |
| Rate for Payer: Adventist Health Commercial |
$7,346.17
|
| Rate for Payer: Blue Shield of California Commercial |
$29,458.13
|
| Rate for Payer: Blue Shield of California EPN |
$18,512.34
|
| Rate for Payer: Cash Price |
$16,528.88
|
| Rate for Payer: Central Health Plan Commercial |
$29,384.67
|
| Rate for Payer: Cigna of CA HMO |
$25,711.59
|
| Rate for Payer: Cigna of CA PPO |
$25,711.59
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25,711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,692.34
|
| Rate for Payer: EPIC Health Plan Senior |
$14,692.34
|
| Rate for Payer: Galaxy Health WC |
$31,221.21
|
| Rate for Payer: Global Benefits Group Commercial |
$22,038.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$33,057.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23,324.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,671.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,346.17
|
| Rate for Payer: Multiplan Commercial |
$27,548.13
|
| Rate for Payer: Networks By Design Commercial |
$18,365.42
|
| Rate for Payer: Prime Health Services Commercial |
$31,221.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,785.08
|
| Rate for Payer: United Healthcare All Other HMO |
$13,417.78
|
| Rate for Payer: United Healthcare HMO Rider |
$13,127.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,029.35
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$59,525.37
|
|
|
Service Code
|
APR-DRG 5194
|
| Min. Negotiated Rate |
$37,594.97 |
| Max. Negotiated Rate |
$59,525.37 |
| Rate for Payer: Adventist Health Medi-Cal |
$37,594.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$44,800.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59,525.37
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$18,903.18
|
|
|
Service Code
|
APR-DRG 5192
|
| Min. Negotiated Rate |
$11,938.85 |
| Max. Negotiated Rate |
$18,903.18 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,938.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14,227.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18,903.18
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$32,307.60
|
|
|
Service Code
|
APR-DRG 5193
|
| Min. Negotiated Rate |
$20,404.80 |
| Max. Negotiated Rate |
$32,307.60 |
| Rate for Payer: Adventist Health Medi-Cal |
$20,404.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$24,315.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32,307.60
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$14,866.74
|
|
|
Service Code
|
APR-DRG 5191
|
| Min. Negotiated Rate |
$9,389.52 |
| Max. Negotiated Rate |
$14,866.74 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,389.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11,189.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,866.74
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$58,169.81
|
|
|
Service Code
|
APR-DRG 5134
|
| Min. Negotiated Rate |
$36,738.83 |
| Max. Negotiated Rate |
$58,169.81 |
| Rate for Payer: Adventist Health Medi-Cal |
$36,738.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$43,780.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58,169.81
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$31,032.62
|
|
|
Service Code
|
APR-DRG 5133
|
| Min. Negotiated Rate |
$19,599.55 |
| Max. Negotiated Rate |
$31,032.62 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,599.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$23,356.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31,032.62
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$15,952.38
|
|
|
Service Code
|
APR-DRG 5131
|
| Min. Negotiated Rate |
$10,075.19 |
| Max. Negotiated Rate |
$15,952.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,075.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,006.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,952.38
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
|
IP
|
$19,706.84
|
|
|
Service Code
|
APR-DRG 5132
|
| Min. Negotiated Rate |
$12,446.42 |
| Max. Negotiated Rate |
$19,706.84 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,446.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14,831.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19,706.84
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC
|
Facility
|
IP
|
$48,290.10
|
|
|
Service Code
|
MSDRG 742
|
| Min. Negotiated Rate |
$22,398.00 |
| Max. Negotiated Rate |
$48,290.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$48,290.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$31,193.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$43,671.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$43,241.96
|
| Rate for Payer: EPIC Health Plan Senior |
$28,827.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$26,207.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$36,690.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$35,117.71
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$26,207.25
|
| Rate for Payer: Prime Health Services Medicare |
$27,779.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$24,996.00
|
| Rate for Payer: United Healthcare All Other HMO |
$24,996.00
|
| Rate for Payer: United Healthcare HMO Rider |
$24,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22,398.00
|
|
