|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
OP
|
$428.80
|
|
|
Service Code
|
CPT J1410
|
| Hospital Charge Code |
1720160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.76 |
| Max. Negotiated Rate |
$2,306.23 |
| Rate for Payer: Adventist Health Medi-Cal |
$372.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,306.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$465.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$409.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$409.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$98.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$108.00
|
| Rate for Payer: BCBS Transplant Transplant |
$257.28
|
| Rate for Payer: Blue Shield of California Commercial |
$411.37
|
| Rate for Payer: Blue Shield of California EPN |
$373.97
|
| Rate for Payer: Caremore Medicare Advantage |
$372.15
|
| Rate for Payer: Cash Price |
$192.96
|
| Rate for Payer: Cash Price |
$192.96
|
| Rate for Payer: Central Health Plan Commercial |
$343.04
|
| Rate for Payer: Cigna of CA HMO |
$300.16
|
| Rate for Payer: Cigna of CA PPO |
$300.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$558.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$502.40
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$372.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$372.15
|
| Rate for Payer: Galaxy Health WC |
$364.48
|
| Rate for Payer: Global Benefits Group Commercial |
$257.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$385.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$321.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$610.32
|
| Rate for Payer: IEHP medi-cal |
$614.04
|
| Rate for Payer: IEHP Medicare Advantage |
$372.15
|
| Rate for Payer: Innovage PACE Commercial |
$558.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$286.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$372.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$85.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$498.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$498.68
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: Networks By Design Commercial |
$214.40
|
| Rate for Payer: Prime Health Services Commercial |
$364.48
|
| Rate for Payer: Prime Health Services Medicare |
$394.47
|
| Rate for Payer: Riverside University Health MISP |
$409.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$257.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$257.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$214.40
|
| Rate for Payer: United Healthcare All Other HMO |
$214.40
|
| Rate for Payer: United Healthcare HMO Rider |
$214.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$214.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$558.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$409.36
|
| Rate for Payer: Vantage Medical Group Senior |
$372.15
|
|
|
Conjunctivoplasty; with conjunctival graft or extensive rearrangement
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 68320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,919.67 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,919.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$2,919.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,941.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,919.67
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,788.26
|
| Rate for Payer: IEHP medi-cal |
$4,817.46
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Innovage PACE Commercial |
$4,379.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,919.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,912.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,912.36
|
| Rate for Payer: Prime Health Services Medicare |
$3,094.85
|
| Rate for Payer: Riverside University Health MISP |
$3,211.64
|
| 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 |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$14,548.91
|
|
|
Service Code
|
APR-DRG 3463
|
| Min. Negotiated Rate |
$12,208.87 |
| Max. Negotiated Rate |
$14,548.91 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,208.87
|
| Rate for Payer: IEHP medi-cal |
$14,548.91
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$7,158.32
|
|
|
Service Code
|
APR-DRG 3461
|
| Min. Negotiated Rate |
$6,006.98 |
| Max. Negotiated Rate |
$7,158.32 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,006.98
|
| Rate for Payer: IEHP medi-cal |
$7,158.32
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$30,201.66
|
|
|
Service Code
|
APR-DRG 3464
|
| Min. Negotiated Rate |
$25,344.05 |
| Max. Negotiated Rate |
$30,201.66 |
| Rate for Payer: Adventist Health Medi-Cal |
$25,344.05
|
| Rate for Payer: IEHP medi-cal |
$30,201.66
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$9,532.87
|
|
|
Service Code
|
APR-DRG 3462
|
| Min. Negotiated Rate |
$7,999.61 |
| Max. Negotiated Rate |
$9,532.87 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,999.61
|
| Rate for Payer: IEHP medi-cal |
$9,532.87
|
|
|
Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy;
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 67880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,919.67 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,919.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| 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 |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,919.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,941.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,919.67
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,788.26
|
| Rate for Payer: IEHP medi-cal |
$4,817.46
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Innovage PACE Commercial |
$4,379.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,919.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,912.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,912.36
|
| Rate for Payer: Prime Health Services Medicare |
$3,094.85
|
| Rate for Payer: Riverside University Health MISP |
$3,211.64
|
| 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 |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer prosthesis)
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 31611
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,022.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| 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 |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,022.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,430.63
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,022.69
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,597.21
|
| Rate for Payer: IEHP medi-cal |
$6,637.44
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Innovage PACE Commercial |
$6,034.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,022.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,390.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,390.40
|
| Rate for Payer: Prime Health Services Medicare |
$4,264.05
|
| Rate for Payer: Riverside University Health MISP |
$4,424.96
|
| 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 |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 42960
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$687.44 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$687.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$687.44
|
| 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 |
$687.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$928.04
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$687.44
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,127.40
|
| Rate for Payer: IEHP medi-cal |
$1,134.28
|
| Rate for Payer: IEHP Medicare Advantage |
$687.44
|
| Rate for Payer: Innovage PACE Commercial |
$1,031.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$687.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$921.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$921.17
|
| Rate for Payer: Prime Health Services Medicare |
$728.69
|
| Rate for Payer: Riverside University Health MISP |
$756.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$6,532.33
|
|
|
Service Code
|
APR-DRG 3841
|
| Min. Negotiated Rate |
$5,481.67 |
| Max. Negotiated Rate |
$6,532.33 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,481.67
|
| Rate for Payer: IEHP medi-cal |
$6,532.33
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$8,187.44
|
|
|
Service Code
|
APR-DRG 3842
|
| Min. Negotiated Rate |
$6,870.58 |
| Max. Negotiated Rate |
$8,187.44 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,870.58
|
| Rate for Payer: IEHP medi-cal |
$8,187.44
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$11,928.77
|
|
|
Service Code
|
APR-DRG 3843
|
| Min. Negotiated Rate |
$10,010.16 |
| Max. Negotiated Rate |
$11,928.77 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,010.16
|
| Rate for Payer: IEHP medi-cal |
$11,928.77
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$19,997.41
|
|
|
Service Code
|
APR-DRG 3844
|
| Min. Negotiated Rate |
$16,781.04 |
| Max. Negotiated Rate |
$19,997.41 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,781.04
|
| Rate for Payer: IEHP medi-cal |
$19,997.41
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]
|
Facility
OP
|
$6,180.48
|
|
|
Service Code
|
CPT J9057
|
| Hospital Charge Code |
ERX219718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.56 |
| Max. Negotiated Rate |
$5,562.43 |
| Rate for Payer: Adventist Health Medi-Cal |
$87.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$166.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$109.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$96.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$96.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$150.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$165.17
|
| Rate for Payer: BCBS Transplant Transplant |
$3,708.29
|
| Rate for Payer: Blue Shield of California Commercial |
$102.64
|
| Rate for Payer: Blue Shield of California EPN |
$93.31
|
| Rate for Payer: Caremore Medicare Advantage |
$87.56
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Central Health Plan Commercial |
$4,944.38
|
| Rate for Payer: Cigna of CA HMO |
$4,326.34
|
| Rate for Payer: Cigna of CA PPO |
$4,326.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$131.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$118.21
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$87.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$87.56
|
| Rate for Payer: Galaxy Health WC |
$5,253.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3,708.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,562.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4,635.36
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$143.60
|
| Rate for Payer: IEHP medi-cal |
$144.48
|
| Rate for Payer: IEHP Medicare Advantage |
$87.56
|
| Rate for Payer: Innovage PACE Commercial |
$131.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,122.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$87.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,236.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$117.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$117.33
|
| Rate for Payer: Multiplan Commercial |
$4,635.36
|
| Rate for Payer: Networks By Design Commercial |
$3,090.24
|
| Rate for Payer: Prime Health Services Commercial |
$5,253.41
|
| Rate for Payer: Prime Health Services Medicare |
$92.81
|
| Rate for Payer: Riverside University Health MISP |
$96.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,708.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,708.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,090.24
|
| Rate for Payer: United Healthcare All Other HMO |
$3,090.24
|
| Rate for Payer: United Healthcare HMO Rider |
$3,090.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,090.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$131.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.32
|
| Rate for Payer: Vantage Medical Group Senior |
$87.56
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]
|
Facility
IP
|
$6,180.48
|
|
|
Service Code
|
CPT J9057
|
| Hospital Charge Code |
ERX219718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,236.10 |
| Max. Negotiated Rate |
$5,562.43 |
| Rate for Payer: Blue Shield of California Commercial |
$4,635.36
|
| Rate for Payer: Blue Shield of California EPN |
$3,300.38
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Central Health Plan Commercial |
$4,944.38
|
| Rate for Payer: Cigna of CA HMO |
$4,326.34
|
| Rate for Payer: Cigna of CA PPO |
$4,326.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,472.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,472.19
|
| Rate for Payer: Galaxy Health WC |
$5,253.41
|
| Rate for Payer: Global Benefits Group Commercial |
$3,708.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$5,562.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,122.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,236.10
|
| Rate for Payer: Multiplan Commercial |
$4,635.36
|
| Rate for Payer: Networks By Design Commercial |
$3,090.24
|
| Rate for Payer: Prime Health Services Commercial |
$5,253.41
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
1715158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.54
|
| Rate for Payer: BCBS Transplant Transplant |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Central Health Plan Commercial |
$2.08
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.95
|
| Rate for Payer: IEHP medi-cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: Riverside University Health MISP |
$1.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
1715158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.39
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Central Health Plan Commercial |
$2.08
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$87,553.71
|
|
|
Service Code
|
APR-DRG 1654
|
| Min. Negotiated Rate |
$73,471.64 |
| Max. Negotiated Rate |
$87,553.71 |
| Rate for Payer: Adventist Health Medi-Cal |
$73,471.64
|
| Rate for Payer: IEHP medi-cal |
$87,553.71
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$64,663.88
|
|
|
Service Code
|
APR-DRG 1653
|
| Min. Negotiated Rate |
$54,263.40 |
| Max. Negotiated Rate |
$64,663.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$54,263.40
|
| Rate for Payer: IEHP medi-cal |
$64,663.88
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$44,165.94
|
|
|
Service Code
|
APR-DRG 1651
|
| Min. Negotiated Rate |
$37,062.32 |
| Max. Negotiated Rate |
$44,165.94 |
| Rate for Payer: Adventist Health Medi-Cal |
$37,062.32
|
| Rate for Payer: IEHP medi-cal |
$44,165.94
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$53,781.57
|
|
|
Service Code
|
APR-DRG 1652
|
| Min. Negotiated Rate |
$45,131.39 |
| Max. Negotiated Rate |
$53,781.57 |
| Rate for Payer: Adventist Health Medi-Cal |
$45,131.39
|
| Rate for Payer: IEHP medi-cal |
$53,781.57
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$45,271.13
|
|
|
Service Code
|
APR-DRG 1662
|
| Min. Negotiated Rate |
$37,989.76 |
| Max. Negotiated Rate |
$45,271.13 |
| Rate for Payer: Adventist Health Medi-Cal |
$37,989.76
|
| Rate for Payer: IEHP medi-cal |
$45,271.13
|
|
|
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$78,921.81
|
|
|
Service Code
|
APR-DRG 1664
|
| Min. Negotiated Rate |
$66,228.10 |
| Max. Negotiated Rate |
$78,921.81 |
| Rate for Payer: Adventist Health Medi-Cal |
$66,228.10
|
| Rate for Payer: IEHP medi-cal |
$78,921.81
|
|
