|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$244.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.25 |
| Max. Negotiated Rate |
$183.38 |
| Rate for Payer: Adventist Health Commercial |
$48.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$157.46
|
| Rate for Payer: Cash Price |
$110.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$132.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$113.20
|
| Rate for Payer: Heritage Provider Network Senior |
$113.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.12
|
| Rate for Payer: Multiplan Commercial |
$183.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$88.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.95
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$244.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.25 |
| Max. Negotiated Rate |
$207.82 |
| Rate for Payer: Adventist Health Commercial |
$48.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$207.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$183.38
|
| Rate for Payer: Blue Shield of California Commercial |
$149.15
|
| Rate for Payer: Blue Shield of California EPN |
$119.32
|
| Rate for Payer: Cash Price |
$110.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$207.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$207.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$156.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$113.20
|
| Rate for Payer: Heritage Provider Network Senior |
$113.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$116.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$44.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$61.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$171.15
|
| Rate for Payer: Multiplan Commercial |
$183.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$97.80
|
| Rate for Payer: TriValley Medical Group Senior |
$97.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$88.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$207.82
|
| Rate for Payer: Vantage Medical Group Senior |
$207.82
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
IP
|
$445.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$334.12 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$286.90
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.26
|
| Rate for Payer: Heritage Provider Network Senior |
$206.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.50
|
|
|
INDOMETHACIN 1 MG INTRAVENOUS SOLUTION [10267]
|
Facility
|
OP
|
$445.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.63 |
| Max. Negotiated Rate |
$378.67 |
| Rate for Payer: Adventist Health Commercial |
$89.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$275.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$245.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$334.12
|
| Rate for Payer: Blue Shield of California Commercial |
$271.75
|
| Rate for Payer: Blue Shield of California EPN |
$217.40
|
| Rate for Payer: Cash Price |
$200.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$378.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$378.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$378.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$285.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.26
|
| Rate for Payer: Heritage Provider Network Senior |
$206.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$212.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$311.84
|
| Rate for Payer: Multiplan Commercial |
$334.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.20
|
| Rate for Payer: TriValley Medical Group Senior |
$178.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$378.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$378.67
|
| Rate for Payer: Vantage Medical Group Senior |
$378.67
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 5026843015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 5026843015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6846240601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 5026843011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 5026843011
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
INDOMETHACIN 25 MG CAPSULE [3897]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6846240601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 5026843111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 5026843111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 6846230201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
INDOMETHACIN 50 MG CAPSULE [3898]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 6846230201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
IP
|
$434.29
|
|
|
Service Code
|
NDC 6934410233
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.61 |
| Max. Negotiated Rate |
$325.72 |
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$279.68
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$234.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$294.01
|
| Rate for Payer: Heritage Provider Network Senior |
$294.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.57
|
| Rate for Payer: Multiplan Commercial |
$325.72
|
|
|
INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]
|
Facility
|
OP
|
$434.29
|
|
|
Service Code
|
NDC 6934410233
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.61 |
| Max. Negotiated Rate |
$369.15 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$268.39
|
| Rate for Payer: Adventist Health Commercial |
$86.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$238.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$325.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$217.23
|
| Rate for Payer: Blue Shield of California Commercial |
$264.92
|
| Rate for Payer: Blue Shield of California EPN |
$211.93
|
| Rate for Payer: Cash Price |
$195.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$369.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$369.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$369.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$268.83
|
| Rate for Payer: Heritage Provider Network Senior |
$268.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$207.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$78.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$304.00
|
| Rate for Payer: Multiplan Commercial |
$325.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$173.72
|
| Rate for Payer: TriValley Medical Group Senior |
$173.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$217.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$369.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$369.15
|
| Rate for Payer: Vantage Medical Group Senior |
$369.15
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 6846232560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 6846232560
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$15,734.61
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$11,742.25 |
| Max. Negotiated Rate |
$15,734.61 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,742.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,742.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,503.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,734.61
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$22,689.08
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$16,932.15 |
| Max. Negotiated Rate |
$22,689.08 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,932.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,932.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,471.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,689.08
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$10,891.48
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$8,127.97 |
| Max. Negotiated Rate |
$10,891.48 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,127.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,127.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,347.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,891.48
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$31,383.38
|
|
|
Service Code
|
MSDRG 854
|
| Min. Negotiated Rate |
$23,420.43 |
| Max. Negotiated Rate |
$31,383.38 |
| Rate for Payer: EPIC Health Plan Medicare |
$23,420.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$23,420.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,933.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$31,383.38
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$76,536.10
|
|
|
Service Code
|
MSDRG 853
|
| Min. Negotiated Rate |
$57,116.49 |
| Max. Negotiated Rate |
$76,536.10 |
| Rate for Payer: EPIC Health Plan Medicare |
$57,116.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$57,116.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65,683.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$76,536.10
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,691.82
|
|
|
Service Code
|
MSDRG 855
|
| Min. Negotiated Rate |
$17,680.46 |
| Max. Negotiated Rate |
$23,691.82 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,680.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,680.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,332.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,691.82
|
|
|
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$23,472.20
|
|
|
Service Code
|
MSDRG 727
|
| Min. Negotiated Rate |
$17,516.57 |
| Max. Negotiated Rate |
$23,472.20 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,516.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,516.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,144.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,472.20
|
|
