|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$18,765.42
|
|
|
Service Code
|
APR-DRG 4463
|
| Min. Negotiated Rate |
$15,747.20 |
| Max. Negotiated Rate |
$18,765.42 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,747.20
|
| Rate for Payer: IEHP medi-cal |
$18,765.42
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$9,802.49
|
|
|
Service Code
|
APR-DRG 4461
|
| Min. Negotiated Rate |
$8,225.87 |
| Max. Negotiated Rate |
$9,802.49 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,225.87
|
| Rate for Payer: IEHP medi-cal |
$9,802.49
|
|
|
Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 53500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,355.72 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| 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 |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: Caremore Medicare Advantage |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| 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
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Urethromeatoplasty, with mucosal advancement
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 53450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,212.08 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,355.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| 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 |
$4,355.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,880.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,355.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,143.38
|
| Rate for Payer: IEHP medi-cal |
$7,186.94
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Innovage PACE Commercial |
$6,533.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,355.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,836.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,836.66
|
| Rate for Payer: Prime Health Services Medicare |
$4,617.06
|
| Rate for Payer: Riverside University Health MISP |
$4,791.29
|
| 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
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type)
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 53400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,465.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| 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 |
$6,465.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,727.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,465.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,602.62
|
| Rate for Payer: IEHP medi-cal |
$10,667.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Innovage PACE Commercial |
$9,697.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,465.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,663.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,663.11
|
| Rate for Payer: Prime Health Services Medicare |
$6,852.91
|
| Rate for Payer: Riverside University Health MISP |
$7,111.51
|
| 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
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 54308
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,465.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| 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 |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$6,465.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,727.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,465.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,602.62
|
| Rate for Payer: IEHP medi-cal |
$10,667.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Innovage PACE Commercial |
$9,697.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,465.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,663.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,663.11
|
| Rate for Payer: Prime Health Services Medicare |
$6,852.91
|
| Rate for Payer: Riverside University Health MISP |
$7,111.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Urethroplasty, reconstruction of female urethra
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 53430
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,465.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| 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 |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$6,465.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,727.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$6,465.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$10,602.62
|
| Rate for Payer: IEHP medi-cal |
$10,667.27
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Innovage PACE Commercial |
$9,697.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6,465.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,663.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,663.11
|
| Rate for Payer: Prime Health Services Medicare |
$6,852.91
|
| Rate for Payer: Riverside University Health MISP |
$7,111.51
|
| 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
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$20,698.15
|
|
|
Service Code
|
APR-DRG 4654
|
| Min. Negotiated Rate |
$17,369.08 |
| Max. Negotiated Rate |
$20,698.15 |
| Rate for Payer: Adventist Health Medi-Cal |
$17,369.08
|
| Rate for Payer: IEHP medi-cal |
$20,698.15
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$7,199.71
|
|
|
Service Code
|
APR-DRG 4652
|
| Min. Negotiated Rate |
$6,041.71 |
| Max. Negotiated Rate |
$7,199.71 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,041.71
|
| Rate for Payer: IEHP medi-cal |
$7,199.71
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$11,915.42
|
|
|
Service Code
|
APR-DRG 4653
|
| Min. Negotiated Rate |
$9,998.95 |
| Max. Negotiated Rate |
$11,915.42 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,998.95
|
| Rate for Payer: IEHP medi-cal |
$11,915.42
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$5,859.61
|
|
|
Service Code
|
APR-DRG 4651
|
| Min. Negotiated Rate |
$4,917.16 |
| Max. Negotiated Rate |
$5,859.61 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,917.16
|
| Rate for Payer: IEHP medi-cal |
$5,859.61
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Blue Shield of California Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Central Health Plan Commercial |
$1.36
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Blue Shield of California Commercial |
$1.94
|
| Rate for Payer: Blue Shield of California EPN |
$1.38
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Central Health Plan Commercial |
$2.06
|
| Rate for Payer: Cigna of CA HMO |
$1.81
|
| Rate for Payer: Cigna of CA PPO |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: Galaxy Health WC |
$2.19
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: Networks By Design Commercial |
$1.68
|
| Rate for Payer: Prime Health Services Commercial |
$2.19
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Blue Shield of California Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.00
|
| Rate for Payer: BCBS Transplant Transplant |
$1.02
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Central Health Plan Commercial |
$1.36
|
| Rate for Payer: Cigna of CA HMO |
$1.19
|
| Rate for Payer: Cigna of CA PPO |
$1.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.53
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.28
|
| Rate for Payer: IEHP medi-cal |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.10
|
| Rate for Payer: Prime Health Services Commercial |
$1.44
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.02
|
| Rate for Payer: Riverside University Health MISP |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Other HMO |
$0.85
|
| Rate for Payer: United Healthcare HMO Rider |
$0.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: BCBS Transplant Transplant |
$1.55
|
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Central Health Plan Commercial |
$2.06
|
| Rate for Payer: Cigna of CA HMO |
$1.81
|
| Rate for Payer: Cigna of CA PPO |
$1.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.03
|
| Rate for Payer: Galaxy Health WC |
$2.19
|
| Rate for Payer: Global Benefits Group Commercial |
$1.55
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.94
|
| Rate for Payer: IEHP medi-cal |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: Networks By Design Commercial |
$1.68
|
| Rate for Payer: Prime Health Services Commercial |
$2.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.55
|
| Rate for Payer: Riverside University Health MISP |
$1.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.55
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.29
|
| Rate for Payer: United Healthcare All Other HMO |
$1.29
|
| Rate for Payer: United Healthcare HMO Rider |
$1.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.19
|
| Rate for Payer: Vantage Medical Group Senior |
$2.19
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.48
|
| Rate for Payer: BCBS Transplant Transplant |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.15
|
| Rate for Payer: IEHP medi-cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: Riverside University Health MISP |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-21
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.48
|
| Rate for Payer: BCBS Transplant Transplant |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.94
|
| Rate for Payer: Cigna of CA PPO |
$2.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.15
|
| Rate for Payer: IEHP medi-cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: Riverside University Health MISP |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-11
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.93
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.22
|
| Rate for Payer: BCBS Transplant Transplant |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Central Health Plan Commercial |
$5.72
|
| 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 |
$6.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.08
|
| Rate for Payer: Global Benefits Group Commercial |
$4.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.36
|
| Rate for Payer: IEHP medi-cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.77
|
| 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 |
$4.65
|
| Rate for Payer: Prime Health Services Commercial |
$6.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.29
|
| Rate for Payer: Riverside University Health MISP |
$2.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.58
|
| Rate for Payer: United Healthcare All Other HMO |
$3.58
|
| Rate for Payer: United Healthcare HMO Rider |
$3.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: Vantage Medical Group Senior |
$6.08
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
NDC 0591-3159-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: BCBS Transplant Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| 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: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$0.92
|
| Rate for Payer: IEHP medi-cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$8.98
|
|
|
Service Code
|
NDC 0904-6221-06
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.08 |
| Rate for Payer: Blue Shield of California Commercial |
$6.74
|
| Rate for Payer: Blue Shield of California EPN |
$4.80
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Central Health Plan Commercial |
$7.18
|
| Rate for Payer: Cigna of CA HMO |
$6.29
|
| Rate for Payer: Cigna of CA PPO |
$6.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: Galaxy Health WC |
$7.63
|
| Rate for Payer: Global Benefits Group Commercial |
$5.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.74
|
| Rate for Payer: Networks By Design Commercial |
$5.84
|
| Rate for Payer: Prime Health Services Commercial |
$7.63
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$7.50
|
|
|
Service Code
|
NDC 42806-503-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Blue Shield of California Commercial |
$5.62
|
| Rate for Payer: Blue Shield of California EPN |
$4.00
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Central Health Plan Commercial |
$6.00
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
OP
|
$3.06
|
|
|
Service Code
|
NDC 0378-1730-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.81
|
| Rate for Payer: BCBS Transplant Transplant |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Central Health Plan Commercial |
$2.45
|
| Rate for Payer: Cigna of CA HMO |
$2.14
|
| Rate for Payer: Cigna of CA PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.22
|
| Rate for Payer: Galaxy Health WC |
$2.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.30
|
| Rate for Payer: IEHP medi-cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: Networks By Design Commercial |
$1.99
|
| Rate for Payer: Prime Health Services Commercial |
$2.60
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: Riverside University Health MISP |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.53
|
| Rate for Payer: United Healthcare All Other HMO |
$1.53
|
| Rate for Payer: United Healthcare HMO Rider |
$1.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.60
|
| Rate for Payer: Vantage Medical Group Senior |
$2.60
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
IP
|
$7.15
|
|
|
Service Code
|
NDC 60687-100-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Blue Shield of California Commercial |
$5.36
|
| Rate for Payer: Blue Shield of California EPN |
$3.82
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Central Health Plan Commercial |
$5.72
|
| Rate for Payer: Cigna of CA HMO |
$5.00
|
| Rate for Payer: Cigna of CA PPO |
$5.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.86
|
| Rate for Payer: Galaxy Health WC |
$6.08
|
| Rate for Payer: Global Benefits Group Commercial |
$4.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.77
|
| 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 |
$4.65
|
| Rate for Payer: Prime Health Services Commercial |
$6.08
|
|
