|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$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: 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: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| 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
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 70710-1483-1
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Blue Distinction Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
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: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| 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
|
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: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| 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
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| 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: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.80
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$0.95
|
|
|
Service Code
|
NDC 59651-421-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Blue Distinction Transplant |
$0.57
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Central Health Plan Commercial |
$0.76
|
| Rate for Payer: Cigna of CA HMO |
$0.67
|
| Rate for Payer: Cigna of CA PPO |
$0.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.81
|
| Rate for Payer: Dignity Health Media |
$0.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.81
|
| Rate for Payer: Global Benefits Group Commercial |
$0.57
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.62
|
| Rate for Payer: Prime Health Services Commercial |
$0.81
|
| Rate for Payer: Riverside University Health System MISP |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO |
$0.48
|
| Rate for Payer: United Healthcare HMO Rider |
$0.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Vantage Medical Group Senior |
$0.81
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| 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: Blue Distinction 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: Dignity Health Media |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$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) Other |
$0.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| 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: Riverside University Health System MISP |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care 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: Blue Distinction 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: Dignity Health Media |
$6.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$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) Other |
$5.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| 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: Riverside University Health System 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
|
$1.50
|
|
|
Service Code
|
NDC 0527-1326-01
|
| Hospital Charge Code |
1711256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Distinction Transplant |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Media |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$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: Aetna of CA HMO/PPO |
$5.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.31
|
| Rate for Payer: Blue Distinction Transplant |
$5.39
|
| Rate for Payer: Blue Shield of California Commercial |
$5.65
|
| Rate for Payer: Blue Shield of California EPN |
$4.39
|
| 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: Dignity Health Commercial/Exchange |
$7.63
|
| Rate for Payer: Dignity Health Media |
$7.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$6.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.42
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$3.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.49
|
| Rate for Payer: United Healthcare All Other HMO |
$4.49
|
| Rate for Payer: United Healthcare HMO Rider |
$4.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.63
|
| Rate for Payer: Vantage Medical Group Senior |
$7.63
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
OP
|
$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: Aetna of CA HMO/PPO |
$4.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care 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: Blue Distinction 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: Dignity Health Media |
$6.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$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) Other |
$5.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.72
|
| 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: Riverside University Health System 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
|
$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: Aetna of CA HMO/PPO |
$4.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.43
|
| Rate for Payer: Blue Distinction Transplant |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$3.67
|
| 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: Dignity Health Commercial/Exchange |
$6.38
|
| Rate for Payer: Dignity Health Media |
$6.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$5.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$3.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO |
$3.75
|
| Rate for Payer: United Healthcare HMO Rider |
$3.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
|
|
URSODIOL 300 MG CAPSULE [11624]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$2.30
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| 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: EPIC Health Plan Commercial |
$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: Kaiser Permanente of CA Commercial/Self Funded |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.17
|
| 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
|
|
|
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: Kaiser Permanente of CA Medi-Cal |
$3.42
|
| 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 ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
1715942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Distinction Transplant |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Media |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
| Rate for Payer: Riverside University Health System MISP |
$0.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
| Rate for Payer: United Healthcare All Other HMO |
$0.75
|
| Rate for Payer: United Healthcare HMO Rider |
$0.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
1715942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Central Health Plan Commercial |
$1.20
|
| Rate for Payer: Cigna of CA HMO |
$1.05
|
| Rate for Payer: Cigna of CA PPO |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Galaxy Health WC |
$1.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.90
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Networks By Design Commercial |
$0.98
|
| Rate for Payer: Prime Health Services Commercial |
$1.28
|
|
|
Use of ophthalmic endoscope (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$7,609.02
|
|
|
Service Code
|
CPT 66990
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$88.64 |
| Max. Negotiated Rate |
$7,609.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| 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: Kaiser Permanente of CA Medi-Cal |
$88.64
|
| 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
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
IP
|
$88.99
|
|
|
Service Code
|
CPT J3358
|
| Hospital Charge Code |
NDG215734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$80.09 |
| Rate for Payer: Blue Shield of California Commercial |
$66.74
|
| Rate for Payer: Blue Shield of California EPN |
$47.52
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Central Health Plan Commercial |
$71.19
|
| Rate for Payer: Cigna of CA HMO |
$62.29
|
| Rate for Payer: Cigna of CA PPO |
$62.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$35.60
|
| Rate for Payer: Galaxy Health WC |
$75.64
|
| Rate for Payer: Global Benefits Group Commercial |
$53.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$80.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$59.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.80
|
| Rate for Payer: Multiplan Commercial |
$66.74
|
| Rate for Payer: Networks By Design Commercial |
$44.50
|
| Rate for Payer: Prime Health Services Commercial |
$75.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Other HMO |
$32.82
|
| Rate for Payer: United Healthcare HMO Rider |
$32.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.37
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
|
OP
|
$88.99
|
|
|
Service Code
|
CPT J3358
|
| Hospital Charge Code |
NDG215734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.62 |
| Max. Negotiated Rate |
$80.09 |
| Rate for Payer: Adventist Health Medi-Cal |
$12.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$78.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.88
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.69
|
| Rate for Payer: Blue Distinction Transplant |
$53.39
|
| Rate for Payer: Blue Shield of California Commercial |
$17.04
|
| Rate for Payer: Blue Shield of California EPN |
$15.49
|
| Rate for Payer: Caremore Medicare Advantage |
$12.62
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Central Health Plan Commercial |
$71.19
|
| Rate for Payer: Cigna of CA HMO |
$62.29
|
| Rate for Payer: Cigna of CA PPO |
$62.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.93
|
| Rate for Payer: Dignity Health Media |
$12.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.04
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$12.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.62
|
| Rate for Payer: Galaxy Health WC |
$75.64
|
| Rate for Payer: Global Benefits Group Commercial |
$53.39
|
| Rate for Payer: Health Management Network EPO/PPO |
$80.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$66.74
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$20.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$20.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.62
|
| Rate for Payer: InnovAge PACE Commercial |
$18.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$59.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.91
|
| Rate for Payer: Multiplan Commercial |
$66.74
|
| Rate for Payer: Networks By Design Commercial |
$44.50
|
| Rate for Payer: Prime Health Services Commercial |
$75.64
|
| Rate for Payer: Prime Health Services Medicare |
$13.38
|
| Rate for Payer: Riverside University Health System MISP |
$13.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$53.39
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$53.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.50
|
| Rate for Payer: United Healthcare All Other HMO |
$44.50
|
| Rate for Payer: United Healthcare HMO Rider |
$44.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$44.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.88
|
| Rate for Payer: Vantage Medical Group Senior |
$12.62
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
IP
|
$31,820.40
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
NDG108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,364.08 |
| Max. Negotiated Rate |
$28,638.36 |
| Rate for Payer: Blue Shield of California Commercial |
$23,865.30
|
| Rate for Payer: Blue Shield of California EPN |
$16,992.09
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Central Health Plan Commercial |
$25,456.32
|
| Rate for Payer: Cigna of CA HMO |
$22,274.28
|
| Rate for Payer: Cigna of CA PPO |
$22,274.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,728.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$12,728.16
|
| Rate for Payer: Galaxy Health WC |
$27,047.34
|
| Rate for Payer: Global Benefits Group Commercial |
$19,092.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$28,638.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21,224.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,123.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,364.08
|
| Rate for Payer: Multiplan Commercial |
$23,865.30
|
| Rate for Payer: Networks By Design Commercial |
$15,910.20
|
| Rate for Payer: Prime Health Services Commercial |
$27,047.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,015.38
|
| Rate for Payer: United Healthcare All Other HMO |
$11,735.36
|
| Rate for Payer: United Healthcare HMO Rider |
$11,480.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10,500.73
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
|
OP
|
$31,820.40
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
NDG108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$153.96 |
| Max. Negotiated Rate |
$28,638.36 |
| Rate for Payer: Adventist Health Medi-Cal |
$153.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$954.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$192.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$169.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$169.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$215.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$235.53
|
| Rate for Payer: Blue Distinction Transplant |
$19,092.24
|
| Rate for Payer: Blue Shield of California Commercial |
$338.55
|
| Rate for Payer: Blue Shield of California EPN |
$307.77
|
| Rate for Payer: Caremore Medicare Advantage |
$153.96
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Central Health Plan Commercial |
$25,456.32
|
| Rate for Payer: Cigna of CA HMO |
$22,274.28
|
| Rate for Payer: Cigna of CA PPO |
$22,274.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$230.93
|
| Rate for Payer: Dignity Health Media |
$153.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$207.84
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$153.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$153.96
|
| Rate for Payer: Galaxy Health WC |
$27,047.34
|
| Rate for Payer: Global Benefits Group Commercial |
$19,092.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$28,638.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$23,865.30
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$252.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$254.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$153.96
|
| Rate for Payer: InnovAge PACE Commercial |
$230.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21,224.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$301.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$153.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,364.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$206.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$206.30
|
| Rate for Payer: Multiplan Commercial |
$23,865.30
|
| Rate for Payer: Networks By Design Commercial |
$15,910.20
|
| Rate for Payer: Prime Health Services Commercial |
$27,047.34
|
| Rate for Payer: Prime Health Services Medicare |
$163.19
|
| Rate for Payer: Riverside University Health System MISP |
$169.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19,092.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19,092.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$15,910.20
|
| Rate for Payer: United Healthcare All Other HMO |
$15,910.20
|
| Rate for Payer: United Healthcare HMO Rider |
$15,910.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,910.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$230.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.35
|
| Rate for Payer: Vantage Medical Group Senior |
$153.96
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$56,078.58
|
|
|
Service Code
|
APR-DRG 5194
|
| Min. Negotiated Rate |
$35,418.05 |
| Max. Negotiated Rate |
$56,078.58 |
| Rate for Payer: Adventist Health Medi-Cal |
$35,418.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$42,206.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56,078.58
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$29,317.08
|
|
|
Service Code
|
APR-DRG 5193
|
| Min. Negotiated Rate |
$18,516.05 |
| Max. Negotiated Rate |
$29,317.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$18,516.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$22,064.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29,317.08
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$18,137.17
|
|
|
Service Code
|
APR-DRG 5192
|
| Min. Negotiated Rate |
$11,455.06 |
| Max. Negotiated Rate |
$18,137.17 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,455.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,650.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,137.17
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$14,272.80
|
|
|
Service Code
|
APR-DRG 5191
|
| Min. Negotiated Rate |
$9,014.40 |
| Max. Negotiated Rate |
$14,272.80 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,014.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$10,742.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,272.80
|
|
