|
ALENDRONATE 70 MG TABLET [29048]
|
Facility
|
IP
|
$1.65
|
|
|
Service Code
|
NDC 6586232904
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.83
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Central Health Plan Commercial |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.16
|
| Rate for Payer: Cigna of CA PPO |
$1.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: EPIC Health Plan Senior |
$0.66
|
| Rate for Payer: Galaxy Health WC |
$1.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Networks By Design Commercial |
$1.07
|
| Rate for Payer: Prime Health Services Commercial |
$1.40
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 4733595688
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| 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 |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR [36982]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 4733595688
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Senior |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION [76353]
|
Facility
|
OP
|
$1,215.88
|
|
|
Service Code
|
HCPCS J0221
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$211.13 |
| Max. Negotiated Rate |
$1,249.11 |
| Rate for Payer: Adventist Health Commercial |
$243.18
|
| Rate for Payer: Adventist Health Medi-Cal |
$211.13
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,249.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$263.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$232.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$232.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$277.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$345.76
|
| Rate for Payer: Blue Shield of California Commercial |
$254.61
|
| Rate for Payer: Blue Shield of California EPN |
$231.46
|
| Rate for Payer: Cash Price |
$547.15
|
| Rate for Payer: Cash Price |
$547.15
|
| Rate for Payer: Central Health Plan Commercial |
$972.70
|
| Rate for Payer: Cigna of CA HMO |
$851.12
|
| Rate for Payer: Cigna of CA PPO |
$851.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$263.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$232.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$232.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$851.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$348.36
|
| Rate for Payer: EPIC Health Plan Senior |
$232.24
|
| Rate for Payer: Galaxy Health WC |
$1,033.50
|
| Rate for Payer: Global Benefits Group Commercial |
$729.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,094.29
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$346.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$211.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$211.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$772.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$394.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$295.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$282.91
|
| Rate for Payer: Multiplan Commercial |
$911.91
|
| Rate for Payer: Networks By Design Commercial |
$607.94
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$211.13
|
| Rate for Payer: Prime Health Services Commercial |
$1,033.50
|
| Rate for Payer: Prime Health Services Medicare |
$223.80
|
| Rate for Payer: Riverside University Health System MISP |
$232.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$729.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$729.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$456.32
|
| Rate for Payer: United Healthcare All Other HMO |
$444.16
|
| Rate for Payer: United Healthcare HMO Rider |
$434.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$398.20
|
| Rate for Payer: Upland Medical Group Pediatric |
$211.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$263.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$232.24
|
| Rate for Payer: Vantage Medical Group Senior |
$232.24
|
|
|
ALGLUCOSIDASE ALFA 50 MG INTRAVENOUS SOLUTION [76353]
|
Facility
|
IP
|
$1,215.88
|
|
|
Service Code
|
HCPCS J0221
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.18 |
| Max. Negotiated Rate |
$1,094.29 |
| Rate for Payer: Adventist Health Commercial |
$243.18
|
| Rate for Payer: Blue Shield of California Commercial |
$975.14
|
| Rate for Payer: Blue Shield of California EPN |
$612.80
|
| Rate for Payer: Cash Price |
$547.15
|
| Rate for Payer: Central Health Plan Commercial |
$972.70
|
| Rate for Payer: Cigna of CA HMO |
$851.12
|
| Rate for Payer: Cigna of CA PPO |
$851.12
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$851.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$486.35
|
| Rate for Payer: EPIC Health Plan Senior |
$486.35
|
| Rate for Payer: Galaxy Health WC |
$1,033.50
|
| Rate for Payer: Global Benefits Group Commercial |
$729.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,094.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$772.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$717.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.18
|
| Rate for Payer: Multiplan Commercial |
$911.91
|
| Rate for Payer: Networks By Design Commercial |
$607.94
|
| Rate for Payer: Prime Health Services Commercial |
$1,033.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$456.32
|
| Rate for Payer: United Healthcare All Other HMO |
$444.16
|
| Rate for Payer: United Healthcare HMO Rider |
$434.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$398.20
|
|
|
ALISKIREN 150 MG TABLET [78653]
|
Facility
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 7083915030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.76
|
| Rate for Payer: Blue Shield of California Commercial |
$9.55
|
| Rate for Payer: Blue Shield of California EPN |
$6.01
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Central Health Plan Commercial |
$12.05
|
| Rate for Payer: Cigna of CA HMO |
$10.54
|
| Rate for Payer: Cigna of CA PPO |
$10.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: EPIC Health Plan Senior |
$6.02
|
| Rate for Payer: Galaxy Health WC |
$12.80
|
| Rate for Payer: Global Benefits Group Commercial |
$9.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.54
|
| Rate for Payer: Multiplan Commercial |
$11.29
|
| Rate for Payer: Networks By Design Commercial |
$9.79
|
| Rate for Payer: Prime Health Services Commercial |
$12.80
|
| Rate for Payer: Riverside University Health System MISP |
$6.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.53
|
| Rate for Payer: United Healthcare All Other HMO |
$7.53
|
| Rate for Payer: United Healthcare HMO Rider |
$7.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.80
|
| Rate for Payer: Vantage Medical Group Senior |
$12.80
|
|
|
ALISKIREN 150 MG TABLET [78653]
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 7083915030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Adventist Health Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California Commercial |
$12.08
|
| Rate for Payer: Blue Shield of California EPN |
$7.59
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Central Health Plan Commercial |
$12.05
|
| Rate for Payer: Cigna of CA HMO |
$10.54
|
| Rate for Payer: Cigna of CA PPO |
$10.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.02
|
| Rate for Payer: EPIC Health Plan Senior |
$6.02
|
| Rate for Payer: Galaxy Health WC |
$12.80
|
| Rate for Payer: Global Benefits Group Commercial |
$9.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.01
|
| Rate for Payer: Multiplan Commercial |
$11.29
|
| Rate for Payer: Networks By Design Commercial |
$9.79
|
| Rate for Payer: Prime Health Services Commercial |
$12.80
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$28,808.96
|
|
|
Service Code
|
APR-DRG 8114
|
| Min. Negotiated Rate |
$18,195.13 |
| Max. Negotiated Rate |
$28,808.96 |
| Rate for Payer: Adventist Health Medi-Cal |
$18,195.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$21,682.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28,808.96
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$15,245.41
|
|
|
Service Code
|
APR-DRG 8113
|
| Min. Negotiated Rate |
$9,628.68 |
| Max. Negotiated Rate |
$15,245.41 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,628.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11,474.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15,245.41
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$7,756.65
|
|
|
Service Code
|
APR-DRG 8112
|
| Min. Negotiated Rate |
$4,898.94 |
| Max. Negotiated Rate |
$7,756.65 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,898.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5,837.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,756.65
|
|
|
ALLERGIC REACTIONS
|
Facility
|
IP
|
$5,375.88
|
|
|
Service Code
|
APR-DRG 8111
|
| Min. Negotiated Rate |
$3,395.29 |
| Max. Negotiated Rate |
$5,375.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,395.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4,046.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,375.88
|
|
|
ALLERGIC REACTIONS WITH MCC
|
Facility
|
IP
|
$44,258.03
|
|
|
Service Code
|
MSDRG 915
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$44,258.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$44,258.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$28,588.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40,025.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$39,755.61
|
| Rate for Payer: EPIC Health Plan Senior |
$26,503.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,094.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33,732.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32,286.38
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$24,094.31
|
| Rate for Payer: Prime Health Services Medicare |
$25,539.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
ALLERGIC REACTIONS WITHOUT MCC
|
Facility
|
IP
|
$17,536.35
|
|
|
Service Code
|
MSDRG 916
|
| Min. Negotiated Rate |
$6,823.00 |
| Max. Negotiated Rate |
$17,536.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17,536.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11,327.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15,859.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$16,650.56
|
| Rate for Payer: EPIC Health Plan Senior |
$11,100.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,091.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14,127.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,522.27
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$10,091.25
|
| Rate for Payer: Prime Health Services Medicare |
$10,696.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$10,506.00
|
| Rate for Payer: United Healthcare All Other HMO |
$8,385.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7,448.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,823.00
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$169,618.97
|
|
|
Service Code
|
APR-DRG 0073
|
| Min. Negotiated Rate |
$107,127.77 |
| Max. Negotiated Rate |
$169,618.97 |
| Rate for Payer: Adventist Health Medi-Cal |
$107,127.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$127,660.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$169,618.97
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$284,687.62
|
|
|
Service Code
|
APR-DRG 0074
|
| Min. Negotiated Rate |
$179,802.71 |
| Max. Negotiated Rate |
$284,687.62 |
| Rate for Payer: Adventist Health Medi-Cal |
$179,802.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$214,264.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$284,687.62
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$105,088.35
|
|
|
Service Code
|
APR-DRG 0071
|
| Min. Negotiated Rate |
$66,371.59 |
| Max. Negotiated Rate |
$105,088.35 |
| Rate for Payer: Adventist Health Medi-Cal |
$66,371.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$79,092.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105,088.35
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$126,247.42
|
|
|
Service Code
|
APR-DRG 0072
|
| Min. Negotiated Rate |
$79,735.21 |
| Max. Negotiated Rate |
$126,247.42 |
| Rate for Payer: Adventist Health Medi-Cal |
$79,735.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$95,017.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$126,247.42
|
|
|
ALLOGENEIC BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$316,299.11
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$165,000.00 |
| Max. Negotiated Rate |
$316,299.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$316,299.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$204,316.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$286,050.06
|
| Rate for Payer: CareMore Health Medicare Advantage |
$166,653.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$274,977.53
|
| Rate for Payer: EPIC Health Plan Senior |
$183,318.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$165,000.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$166,653.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$233,314.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$223,315.09
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$166,653.05
|
| Rate for Payer: Prime Health Services Medicare |
$176,652.23
|
|
|
Allogenic Related Transplant
|
Facility
|
IP
|
$195,000.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$195,000.00 |
| Max. Negotiated Rate |
$195,000.00 |
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$195,000.00
|
|
|
Allogenic Unrelated Transplant
|
Facility
|
IP
|
$240,000.00
|
|
|
Service Code
|
MSDRG 014
|
| Min. Negotiated Rate |
$240,000.00 |
| Max. Negotiated Rate |
$240,000.00 |
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$240,000.00
|
|
|
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 20930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,000.00 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 20931
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$144.08 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$144.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$159.16
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0603211521
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.10
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0378013701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
ALLOPURINOL 100 MG TABLET [310]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 0904704161
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
