|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Blue Shield of California Commercial |
$3.15
|
| Rate for Payer: Blue Shield of California EPN |
$2.24
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$5.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.49
|
| Rate for Payer: Blue Distinction Transplant |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$3.71
|
| Rate for Payer: Blue Shield of California EPN |
$2.89
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Central Health Plan Commercial |
$4.72
|
| Rate for Payer: Cigna of CA HMO |
$3.78
|
| Rate for Payer: Cigna of CA PPO |
$4.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.02
|
| Rate for Payer: Dignity Health Media |
$5.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.36
|
| Rate for Payer: Galaxy Health WC |
$5.02
|
| Rate for Payer: Global Benefits Group Commercial |
$3.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$2.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
| Rate for Payer: Networks By Design Commercial |
$3.84
|
| Rate for Payer: Prime Health Services Commercial |
$5.02
|
| Rate for Payer: Riverside University Health System MISP |
$2.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.95
|
| Rate for Payer: United Healthcare All Other HMO |
$2.95
|
| Rate for Payer: United Healthcare HMO Rider |
$2.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.02
|
| Rate for Payer: Vantage Medical Group Senior |
$5.02
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$5.90
|
|
|
Service Code
|
NDC 63323-184-10
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$5.31 |
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.15
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Central Health Plan Commercial |
$4.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.36
|
| Rate for Payer: Galaxy Health WC |
$5.02
|
| Rate for Payer: Global Benefits Group Commercial |
$3.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Commercial |
$4.42
|
| Rate for Payer: Networks By Design Commercial |
$3.84
|
| Rate for Payer: Prime Health Services Commercial |
$5.02
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 63323-184-11
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.71
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Central Health Plan Commercial |
$2.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Galaxy Health WC |
$2.72
|
| Rate for Payer: Global Benefits Group Commercial |
$1.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$2.08
|
| Rate for Payer: Prime Health Services Commercial |
$2.72
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
NDC 39822-1100-1
|
| Hospital Charge Code |
1757744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.48
|
| Rate for Payer: Blue Distinction Transplant |
$2.52
|
| Rate for Payer: Blue Shield of California Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.05
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Central Health Plan Commercial |
$3.36
|
| Rate for Payer: Cigna of CA HMO |
$2.69
|
| Rate for Payer: Cigna of CA PPO |
$3.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Media |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.68
|
| Rate for Payer: Galaxy Health WC |
$3.57
|
| Rate for Payer: Global Benefits Group Commercial |
$2.52
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Networks By Design Commercial |
$2.73
|
| Rate for Payer: Prime Health Services Commercial |
$3.57
|
| Rate for Payer: Riverside University Health System MISP |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.10
|
| Rate for Payer: United Healthcare All Other HMO |
$2.10
|
| Rate for Payer: United Healthcare HMO Rider |
$2.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
1715010
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Distinction Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
FOLIC ACID ORAL SOLUTION COMPOUND 1 MG/ML [4080276]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 9994-0802-76
|
| Hospital Charge Code |
1715010
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
IP
|
$788.80
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
NDG22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.76 |
| Max. Negotiated Rate |
$709.92 |
| Rate for Payer: Blue Shield of California Commercial |
$591.60
|
| Rate for Payer: Blue Shield of California Commercial |
$900.00
|
| Rate for Payer: Blue Shield of California EPN |
$421.22
|
| Rate for Payer: Blue Shield of California EPN |
$640.80
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Central Health Plan Commercial |
$631.04
|
| Rate for Payer: Central Health Plan Commercial |
$960.00
|
| Rate for Payer: Cigna of CA HMO |
$840.00
|
| Rate for Payer: Cigna of CA HMO |
$552.16
|
| Rate for Payer: Cigna of CA PPO |
$552.16
|
| Rate for Payer: Cigna of CA PPO |
$840.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$315.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$480.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$480.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$315.52
|
| Rate for Payer: Galaxy Health WC |
$1,020.00
|
| Rate for Payer: Galaxy Health WC |
$670.48
|
| Rate for Payer: Global Benefits Group Commercial |
$473.28
|
| Rate for Payer: Global Benefits Group Commercial |
$720.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$709.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,080.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$526.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$800.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$300.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$457.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.00
|
| Rate for Payer: Multiplan Commercial |
$591.60
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: Networks By Design Commercial |
$394.40
|
| Rate for Payer: Networks By Design Commercial |
$600.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,020.00
|
| Rate for Payer: Prime Health Services Commercial |
$670.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$453.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$297.85
|
| Rate for Payer: United Healthcare All Other HMO |
$442.56
|
| Rate for Payer: United Healthcare All Other HMO |
$290.91
|
| Rate for Payer: United Healthcare HMO Rider |
$432.96
|
| Rate for Payer: United Healthcare HMO Rider |
$284.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$260.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$396.00
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
OP
|
$788.80
|
|
|
Service Code
|
CPT J1451
|
| Hospital Charge Code |
NDG22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$709.92 |
| Rate for Payer: Adventist Health Medi-Cal |
$6.06
|
| Rate for Payer: Adventist Health Medi-Cal |
$6.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$91.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$91.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.39
|
| Rate for Payer: Blue Distinction Transplant |
$473.28
|
| Rate for Payer: Blue Distinction Transplant |
$720.00
|
| Rate for Payer: Blue Shield of California Commercial |
$14.14
|
| Rate for Payer: Blue Shield of California Commercial |
$14.14
|
| Rate for Payer: Blue Shield of California EPN |
$12.85
|
| Rate for Payer: Blue Shield of California EPN |
$12.85
|
| Rate for Payer: Caremore Medicare Advantage |
$6.06
|
| Rate for Payer: Caremore Medicare Advantage |
$6.06
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Cash Price |
$354.96
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Central Health Plan Commercial |
$631.04
|
| Rate for Payer: Central Health Plan Commercial |
$960.00
|
| Rate for Payer: Cigna of CA HMO |
$552.16
|
| Rate for Payer: Cigna of CA HMO |
$840.00
|
| Rate for Payer: Cigna of CA PPO |
$552.16
|
| Rate for Payer: Cigna of CA PPO |
$840.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.08
|
| Rate for Payer: Dignity Health Media |
$6.06
|
| Rate for Payer: Dignity Health Media |
$6.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.18
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.06
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$6.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.06
|
| Rate for Payer: Galaxy Health WC |
$670.48
|
| Rate for Payer: Galaxy Health WC |
$1,020.00
|
| Rate for Payer: Global Benefits Group Commercial |
$720.00
|
| Rate for Payer: Global Benefits Group Commercial |
$473.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$709.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,080.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$591.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$900.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$9.93
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$9.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.06
|
| Rate for Payer: InnovAge PACE Commercial |
$9.08
|
| Rate for Payer: InnovAge PACE Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$800.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$526.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$240.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.12
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: Multiplan Commercial |
$591.60
|
| Rate for Payer: Networks By Design Commercial |
$394.40
|
| Rate for Payer: Networks By Design Commercial |
$600.00
|
| Rate for Payer: Prime Health Services Commercial |
$1,020.00
|
| Rate for Payer: Prime Health Services Commercial |
$670.48
|
| Rate for Payer: Prime Health Services Medicare |
$6.42
|
| Rate for Payer: Prime Health Services Medicare |
$6.42
|
| Rate for Payer: Riverside University Health System MISP |
$6.66
|
| Rate for Payer: Riverside University Health System MISP |
$6.66
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$720.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$473.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$473.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$720.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$600.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$394.40
|
| Rate for Payer: United Healthcare All Other HMO |
$394.40
|
| Rate for Payer: United Healthcare All Other HMO |
$600.00
|
| Rate for Payer: United Healthcare HMO Rider |
$600.00
|
| Rate for Payer: United Healthcare HMO Rider |
$394.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$600.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$394.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.66
|
| Rate for Payer: Vantage Medical Group Senior |
$6.06
|
| Rate for Payer: Vantage Medical Group Senior |
$6.06
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
IP
|
$59.66
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1722035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$53.69 |
| Rate for Payer: Blue Shield of California Commercial |
$44.74
|
| Rate for Payer: Blue Shield of California EPN |
$31.86
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Central Health Plan Commercial |
$47.73
|
| Rate for Payer: Cigna of CA HMO |
$41.76
|
| Rate for Payer: Cigna of CA PPO |
$41.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.86
|
| Rate for Payer: Galaxy Health WC |
$50.71
|
| Rate for Payer: Global Benefits Group Commercial |
$35.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: Networks By Design Commercial |
$29.83
|
| Rate for Payer: Prime Health Services Commercial |
$50.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.53
|
| Rate for Payer: United Healthcare All Other HMO |
$22.00
|
| Rate for Payer: United Healthcare HMO Rider |
$21.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.69
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
OP
|
$59.66
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1722035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$53.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.73
|
| Rate for Payer: Blue Distinction Transplant |
$35.80
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Central Health Plan Commercial |
$47.73
|
| Rate for Payer: Cigna of CA HMO |
$41.76
|
| Rate for Payer: Cigna of CA PPO |
$41.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.71
|
| Rate for Payer: Dignity Health Media |
$50.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.86
|
| Rate for Payer: Galaxy Health WC |
$50.71
|
| Rate for Payer: Global Benefits Group Commercial |
$35.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.69
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$44.74
|
| Rate for Payer: Networks By Design Commercial |
$29.83
|
| Rate for Payer: Prime Health Services Commercial |
$50.71
|
| Rate for Payer: Riverside University Health System MISP |
$23.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.83
|
| Rate for Payer: United Healthcare All Other HMO |
$29.83
|
| Rate for Payer: United Healthcare HMO Rider |
$29.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.71
|
| Rate for Payer: Vantage Medical Group Senior |
$50.71
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
OP
|
$110.60
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$99.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$161.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$60.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$104.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$14.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.73
|
| Rate for Payer: Blue Distinction Transplant |
$114.07
|
| Rate for Payer: Blue Distinction Transplant |
$65.18
|
| Rate for Payer: Blue Distinction Transplant |
$66.36
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California Commercial |
$6.56
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Central Health Plan Commercial |
$86.91
|
| Rate for Payer: Central Health Plan Commercial |
$88.48
|
| Rate for Payer: Central Health Plan Commercial |
$152.10
|
| Rate for Payer: Cigna of CA HMO |
$76.05
|
| Rate for Payer: Cigna of CA HMO |
$133.08
|
| Rate for Payer: Cigna of CA HMO |
$77.42
|
| Rate for Payer: Cigna of CA PPO |
$133.08
|
| Rate for Payer: Cigna of CA PPO |
$77.42
|
| Rate for Payer: Cigna of CA PPO |
$76.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$161.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.34
|
| Rate for Payer: Dignity Health Media |
$94.01
|
| Rate for Payer: Dignity Health Media |
$161.60
|
| Rate for Payer: Dignity Health Media |
$92.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$161.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.24
|
| Rate for Payer: Galaxy Health WC |
$161.60
|
| Rate for Payer: Galaxy Health WC |
$94.01
|
| Rate for Payer: Galaxy Health WC |
$92.34
|
| Rate for Payer: Global Benefits Group Commercial |
$114.07
|
| Rate for Payer: Global Benefits Group Commercial |
$65.18
|
| Rate for Payer: Global Benefits Group Commercial |
$66.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$97.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$99.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$142.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$82.95
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$81.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$126.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.02
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: Multiplan Commercial |
$142.59
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: Networks By Design Commercial |
$54.32
|
| Rate for Payer: Networks By Design Commercial |
$55.30
|
| Rate for Payer: Networks By Design Commercial |
$95.06
|
| Rate for Payer: Prime Health Services Commercial |
$92.34
|
| Rate for Payer: Prime Health Services Commercial |
$161.60
|
| Rate for Payer: Prime Health Services Commercial |
$94.01
|
| Rate for Payer: Riverside University Health System MISP |
$43.46
|
| Rate for Payer: Riverside University Health System MISP |
$76.05
|
| Rate for Payer: Riverside University Health System MISP |
$44.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$66.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$66.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$55.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.06
|
| Rate for Payer: United Healthcare All Other HMO |
$55.30
|
| Rate for Payer: United Healthcare All Other HMO |
$54.32
|
| Rate for Payer: United Healthcare All Other HMO |
$95.06
|
| Rate for Payer: United Healthcare HMO Rider |
$54.32
|
| Rate for Payer: United Healthcare HMO Rider |
$55.30
|
| Rate for Payer: United Healthcare HMO Rider |
$95.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$55.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$161.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.34
|
| Rate for Payer: Vantage Medical Group Senior |
$92.34
|
| Rate for Payer: Vantage Medical Group Senior |
$161.60
|
| Rate for Payer: Vantage Medical Group Senior |
$94.01
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
IP
|
$110.60
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$99.54 |
| Rate for Payer: Blue Shield of California Commercial |
$82.95
|
| Rate for Payer: Blue Shield of California Commercial |
$81.48
|
| Rate for Payer: Blue Shield of California Commercial |
$142.59
|
| Rate for Payer: Blue Shield of California EPN |
$101.52
|
| Rate for Payer: Blue Shield of California EPN |
$59.06
|
| Rate for Payer: Blue Shield of California EPN |
$58.01
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Central Health Plan Commercial |
$152.10
|
| Rate for Payer: Central Health Plan Commercial |
$86.91
|
| Rate for Payer: Central Health Plan Commercial |
$88.48
|
| Rate for Payer: Cigna of CA HMO |
$77.42
|
| Rate for Payer: Cigna of CA HMO |
$133.08
|
| Rate for Payer: Cigna of CA HMO |
$76.05
|
| Rate for Payer: Cigna of CA PPO |
$133.08
|
| Rate for Payer: Cigna of CA PPO |
$77.42
|
| Rate for Payer: Cigna of CA PPO |
$76.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.05
|
| Rate for Payer: Galaxy Health WC |
$94.01
|
| Rate for Payer: Galaxy Health WC |
$92.34
|
| Rate for Payer: Galaxy Health WC |
$161.60
|
| Rate for Payer: Global Benefits Group Commercial |
$65.18
|
| Rate for Payer: Global Benefits Group Commercial |
$66.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$97.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$99.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$126.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$81.48
|
| Rate for Payer: Multiplan Commercial |
$142.59
|
| Rate for Payer: Multiplan Commercial |
$82.95
|
| Rate for Payer: Networks By Design Commercial |
$55.30
|
| Rate for Payer: Networks By Design Commercial |
$95.06
|
| Rate for Payer: Networks By Design Commercial |
$54.32
|
| Rate for Payer: Prime Health Services Commercial |
$92.34
|
| Rate for Payer: Prime Health Services Commercial |
$94.01
|
| Rate for Payer: Prime Health Services Commercial |
$161.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.76
|
| Rate for Payer: United Healthcare All Other HMO |
$40.79
|
| Rate for Payer: United Healthcare All Other HMO |
$40.07
|
| Rate for Payer: United Healthcare All Other HMO |
$70.12
|
| Rate for Payer: United Healthcare HMO Rider |
$39.90
|
| Rate for Payer: United Healthcare HMO Rider |
$39.20
|
| Rate for Payer: United Healthcare HMO Rider |
$68.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.74
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$44,772.78
|
|
|
Service Code
|
APR-DRG 3144
|
| Min. Negotiated Rate |
$28,277.54 |
| Max. Negotiated Rate |
$44,772.78 |
| Rate for Payer: Adventist Health Medi-Cal |
$28,277.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$33,697.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44,772.78
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$24,675.93
|
|
|
Service Code
|
APR-DRG 3143
|
| Min. Negotiated Rate |
$15,584.80 |
| Max. Negotiated Rate |
$24,675.93 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,584.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$18,571.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,675.93
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$18,603.60
|
|
|
Service Code
|
APR-DRG 3142
|
| Min. Negotiated Rate |
$11,749.64 |
| Max. Negotiated Rate |
$18,603.60 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,749.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14,001.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,603.60
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
|
IP
|
$17,475.67
|
|
|
Service Code
|
APR-DRG 3141
|
| Min. Negotiated Rate |
$11,037.26 |
| Max. Negotiated Rate |
$17,475.67 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,037.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,152.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,475.67
|
|
|
Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)
|
Facility
|
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 15731
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,703.62 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,482.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,482.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Media |
$4,482.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,351.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,396.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: InnovAge PACE Commercial |
$6,723.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,703.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,006.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,751.45
|
| Rate for Payer: Riverside University Health System MISP |
$4,930.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral
|
Facility
|
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 15576
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$120.25 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3,759.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: InnovAge PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$120.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health System MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet
|
Facility
|
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 15574
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,102.80 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3,759.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: InnovAge PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,102.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health System MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.59
|
| Rate for Payer: Blue Distinction Transplant |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$7.01
|
| Rate for Payer: Blue Shield of California EPN |
$5.45
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Central Health Plan Commercial |
$8.92
|
| Rate for Payer: Cigna of CA HMO |
$7.14
|
| Rate for Payer: Cigna of CA PPO |
$8.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Media |
$9.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
| Rate for Payer: Riverside University Health System MISP |
$4.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.58
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Blue Shield of California Commercial |
$8.36
|
| Rate for Payer: Blue Shield of California EPN |
$5.95
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Central Health Plan Commercial |
$8.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.59
|
| Rate for Payer: Blue Distinction Transplant |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$7.01
|
| Rate for Payer: Blue Shield of California EPN |
$5.45
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Central Health Plan Commercial |
$8.92
|
| Rate for Payer: Cigna of CA HMO |
$7.14
|
| Rate for Payer: Cigna of CA PPO |
$8.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Media |
$9.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
| Rate for Payer: Riverside University Health System MISP |
$4.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.58
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
|
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$10.04 |
| Rate for Payer: Blue Shield of California Commercial |
$8.36
|
| Rate for Payer: Blue Shield of California EPN |
$5.95
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Central Health Plan Commercial |
$8.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$8.36
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.31 |
| Max. Negotiated Rate |
$361.40 |
| Rate for Payer: Blue Shield of California Commercial |
$301.17
|
| Rate for Payer: Blue Shield of California EPN |
$214.43
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Central Health Plan Commercial |
$321.25
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$361.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.31
|
| Rate for Payer: Multiplan Commercial |
$301.17
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$151.63
|
| Rate for Payer: United Healthcare All Other HMO |
$148.10
|
| Rate for Payer: United Healthcare HMO Rider |
$144.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$132.51
|
|
