|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: Riverside University Health MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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 |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 31722-531-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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 |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| 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 |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| 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 |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| 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 |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| 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 |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 58150
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11,461.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13,979.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
|
|
Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
|
Facility
OP
|
$8,389.00
|
|
|
Service Code
|
CPT 22858
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$683.14 |
| Max. Negotiated Rate |
$8,389.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,877.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,389.00
|
| Rate for Payer: Blue Shield of California Commercial |
$951.13
|
| Rate for Payer: Blue Shield of California EPN |
$683.14
|
| 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
|
|
|
Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
|
Facility
OP
|
$38,419.46
|
|
|
Service Code
|
CPT 22856
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,465.14 |
| Max. Negotiated Rate |
$38,419.46 |
| Rate for Payer: Adventist Health Medi-Cal |
$23,284.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,417.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$34,926.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25,612.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23,284.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,877.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,389.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$31,833.27
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: Caremore Medicare Advantage |
$23,284.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34,926.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$31,434.10
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$23,284.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$23,284.52
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$38,186.61
|
| Rate for Payer: IEHP medi-cal |
$38,419.46
|
| Rate for Payer: IEHP Medicare Advantage |
$23,284.52
|
| Rate for Payer: Innovage PACE Commercial |
$34,926.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23,284.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31,201.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31,201.26
|
| Rate for Payer: Multiplan WC |
$31,833.27
|
| Rate for Payer: Preferred Health Network WC |
$32,482.93
|
| Rate for Payer: Prime Health Services Medicare |
$24,681.59
|
| Rate for Payer: Prime Health Services WC |
$31,508.44
|
| Rate for Payer: Riverside University Health MISP |
$25,612.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,813.00
|
| Rate for Payer: United Healthcare All Other HMO |
$27,445.00
|
| Rate for Payer: United Healthcare HMO Rider |
$17,214.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,742.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34,926.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25,612.97
|
| Rate for Payer: Vantage Medical Group Senior |
$23,284.52
|
|
|
Total thyroid lobectomy, unilateral; with or without isthmusectomy
|
Facility
OP
|
$27,445.00
|
|
|
Service Code
|
CPT 60220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,736.00 |
| Max. Negotiated Rate |
$27,445.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,209.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,209.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$7,209.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,813.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,732.43
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,209.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,209.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,823.10
|
| Rate for Payer: IEHP medi-cal |
$11,895.20
|
| Rate for Payer: IEHP Medicare Advantage |
$7,209.21
|
| Rate for Payer: Innovage PACE Commercial |
$10,813.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,209.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,660.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,660.34
|
| Rate for Payer: Prime Health Services Medicare |
$7,641.76
|
| Rate for Payer: Riverside University Health MISP |
$7,930.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,813.00
|
| Rate for Payer: United Healthcare All Other HMO |
$27,445.00
|
| Rate for Payer: United Healthcare HMO Rider |
$17,214.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,742.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: Vantage Medical Group Senior |
$7,209.21
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$8,610.54
|
|
|
Service Code
|
APR-DRG 8163
|
| Min. Negotiated Rate |
$7,225.63 |
| Max. Negotiated Rate |
$8,610.54 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,225.63
|
| Rate for Payer: IEHP medi-cal |
$8,610.54
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$6,514.98
|
|
|
Service Code
|
APR-DRG 8162
|
| Min. Negotiated Rate |
$5,467.12 |
| Max. Negotiated Rate |
$6,514.98 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,467.12
|
| Rate for Payer: IEHP medi-cal |
$6,514.98
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$6,153.25
|
|
|
Service Code
|
APR-DRG 8161
|
| Min. Negotiated Rate |
$5,163.56 |
| Max. Negotiated Rate |
$6,153.25 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,163.56
|
| Rate for Payer: IEHP medi-cal |
$6,153.25
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$15,539.30
|
|
|
Service Code
|
APR-DRG 8164
|
| Min. Negotiated Rate |
$13,039.97 |
| Max. Negotiated Rate |
$15,539.30 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,039.97
|
| Rate for Payer: IEHP medi-cal |
$15,539.30
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$449.10 |
| Rate for Payer: Blue Shield of California Commercial |
$374.25
|
| Rate for Payer: Blue Shield of California EPN |
$266.47
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Central Health Plan Commercial |
$399.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$449.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$449.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$303.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$274.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$241.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$294.81
|
| Rate for Payer: BCBS Transplant Transplant |
$299.40
|
| Rate for Payer: Blue Shield of California Commercial |
$313.87
|
| Rate for Payer: Blue Shield of California EPN |
$244.01
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Central Health Plan Commercial |
$399.20
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$449.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$374.25
|
| Rate for Payer: IEHP medi-cal |
$174.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Riverside University Health MISP |
$199.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
OP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
NDC196140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$449.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$303.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$274.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$241.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$294.81
|
| Rate for Payer: BCBS Transplant Transplant |
$299.40
|
| Rate for Payer: Blue Shield of California Commercial |
$313.87
|
| Rate for Payer: Blue Shield of California EPN |
$244.01
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Central Health Plan Commercial |
$399.20
|
| Rate for Payer: Cigna of CA HMO |
$319.36
|
| Rate for Payer: Cigna of CA PPO |
$369.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$449.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$374.25
|
| Rate for Payer: IEHP medi-cal |
$174.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
| Rate for Payer: Riverside University Health MISP |
$199.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$249.50
|
| Rate for Payer: United Healthcare All Other HMO |
$249.50
|
| Rate for Payer: United Healthcare HMO Rider |
$249.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
IP
|
$499.00
|
|
|
Service Code
|
NDC 9999-1961-40
|
| Hospital Charge Code |
NDC196140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.80 |
| Max. Negotiated Rate |
$449.10 |
| Rate for Payer: Blue Shield of California Commercial |
$374.25
|
| Rate for Payer: Blue Shield of California EPN |
$266.47
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Central Health Plan Commercial |
$399.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.60
|
| Rate for Payer: Galaxy Health WC |
$424.15
|
| Rate for Payer: Global Benefits Group Commercial |
$299.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$449.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.80
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: Networks By Design Commercial |
$324.35
|
| Rate for Payer: Prime Health Services Commercial |
$424.15
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]
|
Facility
OP
|
$3,866.89
|
|
|
Service Code
|
CPT J9352
|
| Hospital Charge Code |
ERX211543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.40 |
| Max. Negotiated Rate |
$3,480.20 |
| Rate for Payer: Adventist Health Medi-Cal |
$338.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,097.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$423.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$372.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$372.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$534.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$585.11
|
| Rate for Payer: BCBS Transplant Transplant |
$2,320.13
|
| Rate for Payer: Blue Shield of California Commercial |
$400.83
|
| Rate for Payer: Blue Shield of California EPN |
$364.39
|
| Rate for Payer: Caremore Medicare Advantage |
$338.40
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,093.51
|
| Rate for Payer: Cigna of CA HMO |
$2,706.82
|
| Rate for Payer: Cigna of CA PPO |
$2,706.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$456.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$338.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$338.40
|
| Rate for Payer: Galaxy Health WC |
$3,286.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2,320.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,480.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2,900.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$554.97
|
| Rate for Payer: IEHP medi-cal |
$558.36
|
| Rate for Payer: IEHP Medicare Advantage |
$338.40
|
| Rate for Payer: Innovage PACE Commercial |
$507.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,579.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$338.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$773.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$453.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$453.45
|
| Rate for Payer: Multiplan Commercial |
$2,900.17
|
| Rate for Payer: Networks By Design Commercial |
$1,933.44
|
| Rate for Payer: Prime Health Services Commercial |
$3,286.86
|
| Rate for Payer: Prime Health Services Medicare |
$358.70
|
| Rate for Payer: Riverside University Health MISP |
$372.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,320.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,320.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,933.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,933.44
|
| Rate for Payer: United Healthcare HMO Rider |
$1,933.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,933.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$507.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$372.24
|
| Rate for Payer: Vantage Medical Group Senior |
$338.40
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION [211543]
|
Facility
IP
|
$3,866.89
|
|
|
Service Code
|
CPT J9352
|
| Hospital Charge Code |
ERX211543
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$773.38 |
| Max. Negotiated Rate |
$3,480.20 |
| Rate for Payer: Blue Shield of California Commercial |
$2,900.17
|
| Rate for Payer: Blue Shield of California EPN |
$2,064.92
|
| Rate for Payer: Cash Price |
$1,740.10
|
| Rate for Payer: Central Health Plan Commercial |
$3,093.51
|
| Rate for Payer: Cigna of CA HMO |
$2,706.82
|
| Rate for Payer: Cigna of CA PPO |
$2,706.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,546.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,546.76
|
| Rate for Payer: Galaxy Health WC |
$3,286.86
|
| Rate for Payer: Global Benefits Group Commercial |
$2,320.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,480.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,579.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$773.38
|
| Rate for Payer: Multiplan Commercial |
$2,900.17
|
| Rate for Payer: Networks By Design Commercial |
$1,933.44
|
| Rate for Payer: Prime Health Services Commercial |
$3,286.86
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
IP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
NDG18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.60
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Central Health Plan Commercial |
$3.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: Networks By Design Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
OP
|
$4.86
|
|
|
Service Code
|
NDC 0517-9203-25
|
| Hospital Charge Code |
NDG18266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.87
|
| Rate for Payer: BCBS Transplant Transplant |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$3.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Central Health Plan Commercial |
$3.89
|
| Rate for Payer: Cigna of CA HMO |
$3.11
|
| Rate for Payer: Cigna of CA PPO |
$3.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.94
|
| Rate for Payer: Galaxy Health WC |
$4.13
|
| Rate for Payer: Global Benefits Group Commercial |
$2.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.37
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.64
|
| Rate for Payer: IEHP medi-cal |
$1.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: Networks By Design Commercial |
$3.16
|
| Rate for Payer: Prime Health Services Commercial |
$4.13
|
| Rate for Payer: Riverside University Health MISP |
$1.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO |
$2.43
|
| Rate for Payer: United Healthcare HMO Rider |
$2.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
ERX4080051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.36
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-51
|
| Hospital Charge Code |
ERX4080051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.72
|
| Rate for Payer: BCBS Transplant Transplant |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$4.03
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.72
|
| Rate for Payer: IEHP medi-cal |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Riverside University Health MISP |
$2.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
IP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-53
|
| Hospital Charge Code |
ERX4080053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.36
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
OP
|
$6.30
|
|
|
Service Code
|
NDC 9994-0800-53
|
| Hospital Charge Code |
ERX4080053
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.72
|
| Rate for Payer: BCBS Transplant Transplant |
$3.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$4.03
|
| Rate for Payer: Cigna of CA PPO |
$4.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.67
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.72
|
| Rate for Payer: IEHP medi-cal |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Riverside University Health MISP |
$2.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
