|
BOTULISM IMMUNE GLOBULIN, HUMAN 100 MG INTRAVENOUS SOLUTION [213747]
|
Facility
|
OP
|
$271,800.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54,360.00 |
| Max. Negotiated Rate |
$244,620.00 |
| Rate for Payer: Adventist Health Commercial |
$54,360.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$165,064.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149,490.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$203,850.00
|
| Rate for Payer: Blue Shield of California Commercial |
$172,321.20
|
| Rate for Payer: Blue Shield of California EPN |
$108,448.20
|
| Rate for Payer: Cash Price |
$122,310.00
|
| Rate for Payer: Central Health Plan Commercial |
$217,440.00
|
| Rate for Payer: Cigna of CA HMO |
$190,260.00
|
| Rate for Payer: Cigna of CA PPO |
$190,260.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$231,030.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$231,030.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$190,260.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$108,720.00
|
| Rate for Payer: EPIC Health Plan Senior |
$108,720.00
|
| Rate for Payer: Galaxy Health WC |
$231,030.00
|
| Rate for Payer: Global Benefits Group Commercial |
$163,080.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$244,620.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$172,593.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$160,362.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54,360.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$190,260.00
|
| Rate for Payer: Multiplan Commercial |
$203,850.00
|
| Rate for Payer: Networks By Design Commercial |
$135,900.00
|
| Rate for Payer: Prime Health Services Commercial |
$231,030.00
|
| Rate for Payer: Riverside University Health System MISP |
$108,720.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$163,080.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$163,080.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$102,006.54
|
| Rate for Payer: United Healthcare All Other HMO |
$99,288.54
|
| Rate for Payer: United Healthcare HMO Rider |
$97,141.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$89,014.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231,030.00
|
| Rate for Payer: Vantage Medical Group Senior |
$231,030.00
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$14,339.01
|
|
|
Service Code
|
APR-DRG 1323
|
| Min. Negotiated Rate |
$9,056.22 |
| Max. Negotiated Rate |
$14,339.01 |
| Rate for Payer: Adventist Health Medi-Cal |
$9,056.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$10,792.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14,339.01
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$8,878.55
|
|
|
Service Code
|
APR-DRG 1322
|
| Min. Negotiated Rate |
$5,607.50 |
| Max. Negotiated Rate |
$8,878.55 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,607.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,682.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8,878.55
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$20,881.11
|
|
|
Service Code
|
APR-DRG 1324
|
| Min. Negotiated Rate |
$13,188.07 |
| Max. Negotiated Rate |
$20,881.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,188.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$15,715.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,881.11
|
|
|
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
|
Facility
|
IP
|
$6,010.35
|
|
|
Service Code
|
APR-DRG 1321
|
| Min. Negotiated Rate |
$3,796.01 |
| Max. Negotiated Rate |
$6,010.35 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,796.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$4,523.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6,010.35
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$19,898.19
|
|
|
Service Code
|
APR-DRG 0563
|
| Min. Negotiated Rate |
$12,567.28 |
| Max. Negotiated Rate |
$19,898.19 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,567.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14,976.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19,898.19
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$12,778.01
|
|
|
Service Code
|
APR-DRG 0562
|
| Min. Negotiated Rate |
$8,070.32 |
| Max. Negotiated Rate |
$12,778.01 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,070.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$9,617.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12,778.01
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$9,233.05
|
|
|
Service Code
|
APR-DRG 0561
|
| Min. Negotiated Rate |
$5,831.40 |
| Max. Negotiated Rate |
$9,233.05 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,831.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6,949.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9,233.05
|
|
|
BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA
|
Facility
|
IP
|
$34,192.89
|
|
|
Service Code
|
APR-DRG 0564
|
| Min. Negotiated Rate |
$21,595.51 |
| Max. Negotiated Rate |
$34,192.89 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,595.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$25,734.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$34,192.89
|
|
|
BREAST AUGMENTATION WITH IMPLANT
|
Facility
|
OP
|
$28,817.00
|
|
|
Service Code
|
CPT 19325
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$230.53 |
| Max. Negotiated Rate |
$28,817.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,512.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15,768.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11,563.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10,512.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,924.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$19,372.29
|
| Rate for Payer: Blue Shield of California Commercial |
$13,231.02
|
| Rate for Payer: Blue Shield of California EPN |
$8,315.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15,768.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$11,563.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10,512.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$17,345.36
|
| Rate for Payer: EPIC Health Plan Senior |
$11,563.57
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$17,240.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$230.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,512.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$254.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14,717.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,086.54
|
| Rate for Payer: Multiplan WC |
$19,372.29
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$10,512.34
|
| Rate for Payer: Preferred Health Network WC |
$19,767.64
|
| Rate for Payer: Prime Health Services Medicare |
$11,143.08
|
| Rate for Payer: Prime Health Services WC |
$19,174.61
|
| Rate for Payer: Riverside University Health System MISP |
$11,563.57
|
| Rate for Payer: United Healthcare All Other HMO |
$28,817.00
|
| Rate for Payer: United Healthcare HMO Rider |
$18,075.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,561.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$10,512.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15,768.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11,563.57
|
| Rate for Payer: Vantage Medical Group Senior |
$10,512.34
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$56,341.08
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$56,341.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$56,341.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$36,394.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50,952.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$50,203.30
|
| Rate for Payer: EPIC Health Plan Senior |
$33,468.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30,426.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42,596.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40,771.16
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$30,426.24
|
| Rate for Payer: Prime Health Services Medicare |
$32,251.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$50,771.98
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$50,771.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$50,771.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$32,796.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45,916.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$45,387.92
|
| Rate for Payer: EPIC Health Plan Senior |
$30,258.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27,507.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$38,510.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36,860.49
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$27,507.83
|
| Rate for Payer: Prime Health Services Medicare |
$29,158.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$51,593.47
|
|
|
Service Code
|
APR-DRG 3634
|
| Min. Negotiated Rate |
$32,585.35 |
| Max. Negotiated Rate |
$51,593.47 |
| Rate for Payer: Adventist Health Medi-Cal |
$32,585.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$38,830.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51,593.47
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$17,994.77
|
|
|
Service Code
|
APR-DRG 3631
|
| Min. Negotiated Rate |
$11,365.12 |
| Max. Negotiated Rate |
$17,994.77 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,365.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$13,543.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17,994.77
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$43,252.72
|
|
|
Service Code
|
APR-DRG 3633
|
| Min. Negotiated Rate |
$27,317.51 |
| Max. Negotiated Rate |
$43,252.72 |
| Rate for Payer: Adventist Health Medi-Cal |
$27,317.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$32,553.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$43,252.72
|
|
|
BREAST PROCEDURES EXCEPT MASTECTOMY
|
Facility
|
IP
|
$31,499.91
|
|
|
Service Code
|
APR-DRG 3632
|
| Min. Negotiated Rate |
$19,894.68 |
| Max. Negotiated Rate |
$31,499.91 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,894.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$23,707.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31,499.91
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 19318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,709.75 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,540.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,572.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,138.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$13,202.52
|
| Rate for Payer: Blue Shield of California Commercial |
$6,228.07
|
| Rate for Payer: Blue Shield of California EPN |
$3,914.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$14,091.61
|
| Rate for Payer: EPIC Health Plan Senior |
$9,394.41
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14,006.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,709.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,888.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,956.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Preferred Health Network WC |
$13,471.96
|
| Rate for Payer: Prime Health Services Medicare |
$9,052.79
|
| Rate for Payer: Prime Health Services WC |
$13,067.80
|
| Rate for Payer: Riverside University Health System MISP |
$9,394.41
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$8,540.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
OP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$184.33 |
| Max. Negotiated Rate |
$14,778.50 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Adventist Health Medi-Cal |
$279.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$490.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$418.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$279.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$184.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$230.03
|
| Rate for Payer: Blue Shield of California Commercial |
$309.99
|
| Rate for Payer: Blue Shield of California EPN |
$281.81
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Central Health Plan Commercial |
$13,136.45
|
| Rate for Payer: Cigna of CA HMO |
$11,494.39
|
| Rate for Payer: Cigna of CA PPO |
$11,494.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$349.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$307.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$307.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,494.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$460.70
|
| Rate for Payer: EPIC Health Plan Senior |
$307.13
|
| Rate for Payer: Galaxy Health WC |
$13,957.48
|
| Rate for Payer: Global Benefits Group Commercial |
$9,852.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$14,778.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$457.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$279.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$279.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,427.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$510.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$390.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,284.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$374.14
|
| Rate for Payer: Multiplan Commercial |
$12,315.42
|
| Rate for Payer: Networks By Design Commercial |
$8,210.28
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$279.21
|
| Rate for Payer: Prime Health Services Commercial |
$13,957.48
|
| Rate for Payer: Prime Health Services Medicare |
$295.96
|
| Rate for Payer: Riverside University Health System MISP |
$307.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9,852.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9,852.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,162.64
|
| Rate for Payer: United Healthcare All Other HMO |
$5,998.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5,868.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,377.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$279.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$349.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$307.13
|
| Rate for Payer: Vantage Medical Group Senior |
$307.13
|
|
|
BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]
|
Facility
|
IP
|
$16,420.56
|
|
|
Service Code
|
HCPCS J9042
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,284.11 |
| Max. Negotiated Rate |
$14,778.50 |
| Rate for Payer: Adventist Health Commercial |
$3,284.11
|
| Rate for Payer: Blue Shield of California Commercial |
$13,169.29
|
| Rate for Payer: Blue Shield of California EPN |
$8,275.96
|
| Rate for Payer: Cash Price |
$7,389.25
|
| Rate for Payer: Central Health Plan Commercial |
$13,136.45
|
| Rate for Payer: Cigna of CA HMO |
$11,494.39
|
| Rate for Payer: Cigna of CA PPO |
$11,494.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11,494.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,568.22
|
| Rate for Payer: EPIC Health Plan Senior |
$6,568.22
|
| Rate for Payer: Galaxy Health WC |
$13,957.48
|
| Rate for Payer: Global Benefits Group Commercial |
$9,852.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$14,778.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10,427.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,688.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,284.11
|
| Rate for Payer: Multiplan Commercial |
$12,315.42
|
| Rate for Payer: Networks By Design Commercial |
$8,210.28
|
| Rate for Payer: Prime Health Services Commercial |
$13,957.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,162.64
|
| Rate for Payer: United Healthcare All Other HMO |
$5,998.43
|
| Rate for Payer: United Healthcare HMO Rider |
$5,868.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,377.73
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$49.75
|
|
|
Service Code
|
NDC 0023917705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$44.77 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.94
|
| Rate for Payer: Blue Shield of California Commercial |
$31.54
|
| Rate for Payer: Blue Shield of California EPN |
$19.85
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Central Health Plan Commercial |
$39.80
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$34.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$31.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34.83
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
| Rate for Payer: Riverside University Health System MISP |
$19.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.88
|
| Rate for Payer: United Healthcare All Other HMO |
$24.88
|
| Rate for Payer: United Healthcare HMO Rider |
$24.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.29
|
| Rate for Payer: Vantage Medical Group Senior |
$42.29
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$49.75
|
|
|
Service Code
|
NDC 0023917705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$44.77 |
| Rate for Payer: Adventist Health Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$39.90
|
| Rate for Payer: Blue Shield of California EPN |
$25.07
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Central Health Plan Commercial |
$39.80
|
| Rate for Payer: Cigna of CA HMO |
$34.83
|
| Rate for Payer: Cigna of CA PPO |
$34.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$34.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.90
|
| Rate for Payer: EPIC Health Plan Senior |
$19.90
|
| Rate for Payer: Galaxy Health WC |
$42.29
|
| Rate for Payer: Global Benefits Group Commercial |
$29.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$31.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.95
|
| Rate for Payer: Multiplan Commercial |
$37.31
|
| Rate for Payer: Networks By Design Commercial |
$32.34
|
| Rate for Payer: Prime Health Services Commercial |
$42.29
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
IP
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Blue Shield of California Commercial |
$29.51
|
| Rate for Payer: Blue Shield of California EPN |
$18.55
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Central Health Plan Commercial |
$29.44
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
|
|
BRIMONIDINE 0.15 % EYE DROPS [31158]
|
Facility
|
OP
|
$36.80
|
|
|
Service Code
|
NDC 6131414405
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Adventist Health Commercial |
$7.36
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$17.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.41
|
| Rate for Payer: Blue Shield of California Commercial |
$23.33
|
| Rate for Payer: Blue Shield of California EPN |
$14.68
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Central Health Plan Commercial |
$29.44
|
| Rate for Payer: Cigna of CA HMO |
$25.76
|
| Rate for Payer: Cigna of CA PPO |
$25.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: EPIC Health Plan Senior |
$14.72
|
| Rate for Payer: Galaxy Health WC |
$31.28
|
| Rate for Payer: Global Benefits Group Commercial |
$22.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$27.60
|
| Rate for Payer: Networks By Design Commercial |
$23.92
|
| Rate for Payer: Prime Health Services Commercial |
$31.28
|
| Rate for Payer: Riverside University Health System MISP |
$14.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.40
|
| Rate for Payer: United Healthcare All Other HMO |
$18.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.28
|
| Rate for Payer: Vantage Medical Group Senior |
$31.28
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 7006923101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
|
|
BRIMONIDINE 0.2 % EYE DROPS [17881]
|
Facility
|
OP
|
$1.47
|
|
|
Service Code
|
NDC 7006923101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.03
|
| Rate for Payer: Cigna of CA PPO |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.03
|
| Rate for Payer: Multiplan Commercial |
$1.10
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.25
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Vantage Medical Group Senior |
$1.25
|
|
