|
DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: IEHP medi-cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
DOPAMINE 40 MG/50 ML D5.2NS SYRINGE [4080662]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [14846]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
1771255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080663
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
DOPAMINE 80 MG/50 ML D5.2NS SYRINGE [4080663]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
NDC4080663
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: IEHP medi-cal |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
IP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$54.48 |
| Rate for Payer: Blue Shield of California Commercial |
$45.40
|
| Rate for Payer: Blue Shield of California EPN |
$32.32
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Central Health Plan Commercial |
$48.42
|
| Rate for Payer: Cigna of CA HMO |
$42.37
|
| Rate for Payer: Cigna of CA PPO |
$42.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.21
|
| Rate for Payer: Galaxy Health WC |
$51.45
|
| Rate for Payer: Global Benefits Group Commercial |
$36.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.11
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$39.34
|
| Rate for Payer: Prime Health Services Commercial |
$51.45
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
IP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$54.48 |
| Rate for Payer: Blue Shield of California Commercial |
$45.40
|
| Rate for Payer: Blue Shield of California EPN |
$32.32
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Central Health Plan Commercial |
$48.42
|
| Rate for Payer: Cigna of CA HMO |
$42.37
|
| Rate for Payer: Cigna of CA PPO |
$42.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.21
|
| Rate for Payer: Galaxy Health WC |
$51.45
|
| Rate for Payer: Global Benefits Group Commercial |
$36.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.11
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$39.34
|
| Rate for Payer: Prime Health Services Commercial |
$51.45
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
OP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-40
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$54.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$36.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.76
|
| Rate for Payer: BCBS Transplant Transplant |
$36.32
|
| Rate for Payer: Blue Shield of California Commercial |
$38.07
|
| Rate for Payer: Blue Shield of California EPN |
$29.60
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Central Health Plan Commercial |
$48.42
|
| Rate for Payer: Cigna of CA HMO |
$42.37
|
| Rate for Payer: Cigna of CA PPO |
$42.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.21
|
| Rate for Payer: Galaxy Health WC |
$51.45
|
| Rate for Payer: Global Benefits Group Commercial |
$36.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.40
|
| Rate for Payer: IEHP medi-cal |
$21.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.11
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$39.34
|
| Rate for Payer: Prime Health Services Commercial |
$51.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$36.32
|
| Rate for Payer: Riverside University Health MISP |
$24.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.26
|
| Rate for Payer: United Healthcare All Other HMO |
$30.26
|
| Rate for Payer: United Healthcare HMO Rider |
$30.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.45
|
| Rate for Payer: Vantage Medical Group Senior |
$51.45
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION [12211]
|
Facility
OP
|
$60.53
|
|
|
Service Code
|
NDC 50242-100-39
|
| Hospital Charge Code |
1744070
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$54.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$36.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.76
|
| Rate for Payer: BCBS Transplant Transplant |
$36.32
|
| Rate for Payer: Blue Shield of California Commercial |
$38.07
|
| Rate for Payer: Blue Shield of California EPN |
$29.60
|
| Rate for Payer: Cash Price |
$27.24
|
| Rate for Payer: Central Health Plan Commercial |
$48.42
|
| Rate for Payer: Cigna of CA HMO |
$42.37
|
| Rate for Payer: Cigna of CA PPO |
$42.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.21
|
| Rate for Payer: Galaxy Health WC |
$51.45
|
| Rate for Payer: Global Benefits Group Commercial |
$36.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.40
|
| Rate for Payer: IEHP medi-cal |
$21.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.11
|
| Rate for Payer: Multiplan Commercial |
$45.40
|
| Rate for Payer: Networks By Design Commercial |
$39.34
|
| Rate for Payer: Prime Health Services Commercial |
$51.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$36.32
|
| Rate for Payer: Riverside University Health MISP |
$24.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.26
|
| Rate for Payer: United Healthcare All Other HMO |
$30.26
|
| Rate for Payer: United Healthcare HMO Rider |
$30.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.45
|
| Rate for Payer: Vantage Medical Group Senior |
$51.45
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$55,794.38
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$46,820.46 |
| Max. Negotiated Rate |
$55,794.38 |
| Rate for Payer: Adventist Health Medi-Cal |
$46,820.46
|
| Rate for Payer: IEHP medi-cal |
$55,794.38
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$39,557.00
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$33,194.69 |
| Max. Negotiated Rate |
$39,557.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$33,194.69
|
| Rate for Payer: IEHP medi-cal |
$39,557.00
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$82,561.71
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$69,282.55 |
| Max. Negotiated Rate |
$82,561.71 |
| Rate for Payer: Adventist Health Medi-Cal |
$69,282.55
|
| Rate for Payer: IEHP medi-cal |
$82,561.71
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
IP
|
$33,298.31
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$27,942.64 |
| Max. Negotiated Rate |
$33,298.31 |
| Rate for Payer: Adventist Health Medi-Cal |
$27,942.64
|
| Rate for Payer: IEHP medi-cal |
$33,298.31
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$59,172.67
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$49,655.39 |
| Max. Negotiated Rate |
$59,172.67 |
| Rate for Payer: Adventist Health Medi-Cal |
$49,655.39
|
| Rate for Payer: IEHP medi-cal |
$59,172.67
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$81,444.51
|
|
|
Service Code
|
APR-DRG 3033
|
| Min. Negotiated Rate |
$68,345.04 |
| Max. Negotiated Rate |
$81,444.51 |
| Rate for Payer: Adventist Health Medi-Cal |
$68,345.04
|
| Rate for Payer: IEHP medi-cal |
$81,444.51
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$107,565.80
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$90,265.01 |
| Max. Negotiated Rate |
$107,565.80 |
| Rate for Payer: Adventist Health Medi-Cal |
$90,265.01
|
| Rate for Payer: IEHP medi-cal |
$107,565.80
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
IP
|
$49,266.06
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$41,342.15 |
| Max. Negotiated Rate |
$49,266.06 |
| Rate for Payer: Adventist Health Medi-Cal |
$41,342.15
|
| Rate for Payer: IEHP medi-cal |
$49,266.06
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 24208-486-10
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Blue Shield of California Commercial |
$4.50
|
| Rate for Payer: Blue Shield of California EPN |
$3.20
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 42571-147-26
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: IEHP medi-cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Riverside University Health MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 24208-486-10
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: IEHP medi-cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Riverside University Health MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
OP
|
$2.40
|
|
|
Service Code
|
NDC 61314-030-02
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.42
|
| Rate for Payer: BCBS Transplant Transplant |
$1.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.92
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.80
|
| Rate for Payer: IEHP medi-cal |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: Riverside University Health MISP |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.20
|
| Rate for Payer: United Healthcare All Other HMO |
$1.20
|
| Rate for Payer: United Healthcare HMO Rider |
$1.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 50383-233-10
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.54
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: IEHP medi-cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Riverside University Health MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [22982]
|
Facility
IP
|
$2.40
|
|
|
Service Code
|
NDC 61314-030-02
|
| Hospital Charge Code |
1740314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Central Health Plan Commercial |
$1.92
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$1.56
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
|
