|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.11
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.12
|
| Rate for Payer: Blue Shield of California Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: InnovAge PACE Commercial |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
| Rate for Payer: Riverside University Health System MISP |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Other HMO |
$6.07
|
| Rate for Payer: United Healthcare HMO Rider |
$6.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.11
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.11
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.12
|
| Rate for Payer: Blue Shield of California Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: InnovAge PACE Commercial |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
| Rate for Payer: Riverside University Health System MISP |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Other HMO |
$6.07
|
| Rate for Payer: United Healthcare HMO Rider |
$6.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.12
|
| Rate for Payer: Blue Shield of California Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: InnovAge PACE Commercial |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
| Rate for Payer: Riverside University Health System MISP |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Other HMO |
$6.07
|
| Rate for Payer: United Healthcare HMO Rider |
$6.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-70
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.12
|
| Rate for Payer: Blue Shield of California Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: InnovAge PACE Commercial |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.49
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
| Rate for Payer: Riverside University Health System MISP |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.07
|
| Rate for Payer: United Healthcare All Other HMO |
$6.07
|
| Rate for Payer: United Healthcare HMO Rider |
$6.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.31
|
| Rate for Payer: Vantage Medical Group Senior |
$10.31
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Adventist Health Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$6.11
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Central Health Plan Commercial |
$9.70
|
| Rate for Payer: Cigna of CA HMO |
$8.49
|
| Rate for Payer: Cigna of CA PPO |
$8.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.85
|
| Rate for Payer: EPIC Health Plan Senior |
$4.85
|
| Rate for Payer: Galaxy Health WC |
$10.31
|
| Rate for Payer: Global Benefits Group Commercial |
$7.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$9.10
|
| Rate for Payer: Networks By Design Commercial |
$7.88
|
| Rate for Payer: Prime Health Services Commercial |
$10.31
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.06
|
| Rate for Payer: Blue Shield of California Commercial |
$9.42
|
| Rate for Payer: Blue Shield of California EPN |
$6.15
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: EPIC Health Plan Senior |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: InnovAge PACE Commercial |
$7.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.79
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
| Rate for Payer: Riverside University Health System MISP |
$6.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.71
|
| Rate for Payer: United Healthcare All Other HMO |
$7.71
|
| Rate for Payer: United Healthcare HMO Rider |
$7.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Blue Shield of California Commercial |
$11.92
|
| Rate for Payer: Blue Shield of California EPN |
$7.77
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: EPIC Health Plan Senior |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$20,553.69
|
|
|
Service Code
|
APR-DRG 2514
|
| Min. Negotiated Rate |
$12,981.28 |
| Max. Negotiated Rate |
$20,553.69 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,981.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$15,469.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,553.69
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$9,995.39
|
|
|
Service Code
|
APR-DRG 2512
|
| Min. Negotiated Rate |
$6,312.88 |
| Max. Negotiated Rate |
$9,995.39 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,312.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,522.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,995.39
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$7,789.41
|
|
|
Service Code
|
APR-DRG 2511
|
| Min. Negotiated Rate |
$4,919.63 |
| Max. Negotiated Rate |
$7,789.41 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,919.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5,862.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7,789.41
|
|
|
APR-DRG 41.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$13,211.17
|
|
|
Service Code
|
APR-DRG 2513
|
| Min. Negotiated Rate |
$8,343.90 |
| Max. Negotiated Rate |
$13,211.17 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,343.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9,943.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13,211.17
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$36,020.11
|
|
|
Service Code
|
APR-DRG 5434
|
| Min. Negotiated Rate |
$22,749.54 |
| Max. Negotiated Rate |
$36,020.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,749.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$27,109.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,020.11
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$11,046.66
|
|
|
Service Code
|
APR-DRG 5432
|
| Min. Negotiated Rate |
$6,976.84 |
| Max. Negotiated Rate |
$11,046.66 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,976.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,314.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,046.66
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$8,438.18
|
|
|
Service Code
|
APR-DRG 5431
|
| Min. Negotiated Rate |
$5,329.38 |
| Max. Negotiated Rate |
$8,438.18 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,329.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,350.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,438.18
|
|
|
APR-DRG 41.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$15,961.20
|
|
|
Service Code
|
APR-DRG 5433
|
| Min. Negotiated Rate |
$10,080.76 |
| Max. Negotiated Rate |
$15,961.20 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,080.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,012.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,961.20
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$6,976.72
|
|
|
Service Code
|
APR-DRG 5642
|
| Min. Negotiated Rate |
$4,406.35 |
| Max. Negotiated Rate |
$6,976.72 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,406.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$5,250.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,976.72
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$5,216.93
|
|
|
Service Code
|
APR-DRG 5641
|
| Min. Negotiated Rate |
$3,294.90 |
| Max. Negotiated Rate |
$5,216.93 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,294.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3,926.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,216.93
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$33,294.38
|
|
|
Service Code
|
APR-DRG 5644
|
| Min. Negotiated Rate |
$21,028.03 |
| Max. Negotiated Rate |
$33,294.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,028.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$25,058.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,294.38
|
|
|
APR-DRG 41.00: ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY
|
Facility
|
IP
|
$10,357.24
|
|
|
Service Code
|
APR-DRG 5643
|
| Min. Negotiated Rate |
$6,541.42 |
| Max. Negotiated Rate |
$10,357.24 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,541.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,795.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,357.24
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$12,865.07
|
|
|
Service Code
|
APR-DRG 1931
|
| Min. Negotiated Rate |
$8,125.31 |
| Max. Negotiated Rate |
$12,865.07 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,125.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9,682.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,865.07
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$17,809.52
|
|
|
Service Code
|
APR-DRG 1932
|
| Min. Negotiated Rate |
$11,248.12 |
| Max. Negotiated Rate |
$17,809.52 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,248.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,404.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,809.52
|
|
|
APR-DRG 41.00: ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$23,794.19
|
|
|
Service Code
|
APR-DRG 1933
|
| Min. Negotiated Rate |
$15,027.91 |
| Max. Negotiated Rate |
$23,794.19 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,027.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17,908.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,794.19
|
|
