|
MAGNESIUM SULFATE 4 GRAM/50 ML (8 %) IN WATER INTRAVENOUS PIGGYBACK [4721]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
NDG4721
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1757224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1757224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
OP
|
$0.65
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1720064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.55
|
| Rate for Payer: Dignity Health Senior |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.55
|
| Rate for Payer: Vantage Medical Group Senior |
$0.55
|
|
|
MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]
|
Facility
IP
|
$0.65
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1720064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Senior |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1720064
|
|
Hospital Revenue Code
|
636
|
| 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 |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$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 Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
NDG4720A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1720064
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
IP
|
$0.67
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1757224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
IP
|
$0.24
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
NDG4720A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
|
|
MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
CPT J3475
|
| Hospital Charge Code |
1757224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$1.01
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: IEHP Medi-Cal |
$8.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$1.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 11068-01006
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 11068-01006
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]
|
Facility
IP
|
$1.04
|
|
|
Service Code
|
NDC 9994-0804-34
|
| Hospital Charge Code |
1715016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
|
|
MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]
|
Facility
OP
|
$1.04
|
|
|
Service Code
|
NDC 9994-0804-34
|
| Hospital Charge Code |
1715016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.88
|
| Rate for Payer: Dignity Health Senior |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Vantage Medical Group Senior |
$0.88
|
|
|
MAJOR ABDOMINAL VASCULAR PROCEDURES
|
Facility
IP
|
$25,555.89
|
|
|
Service Code
|
APR-DRG 1691
|
| Min. Negotiated Rate |
$25,555.89 |
| Max. Negotiated Rate |
$25,555.89 |
| Rate for Payer: IEHP Medi-Cal |
$25,555.89
|
|
|
MAJOR ABDOMINAL VASCULAR PROCEDURES
|
Facility
IP
|
$25,900.13
|
|
|
Service Code
|
APR-DRG 1692
|
| Min. Negotiated Rate |
$25,900.13 |
| Max. Negotiated Rate |
$25,900.13 |
| Rate for Payer: IEHP Medi-Cal |
$25,900.13
|
|
|
MAJOR ABDOMINAL VASCULAR PROCEDURES
|
Facility
IP
|
$55,058.54
|
|
|
Service Code
|
APR-DRG 1694
|
| Min. Negotiated Rate |
$55,058.54 |
| Max. Negotiated Rate |
$55,058.54 |
| Rate for Payer: IEHP Medi-Cal |
$55,058.54
|
|
|
MAJOR ABDOMINAL VASCULAR PROCEDURES
|
Facility
IP
|
$33,843.38
|
|
|
Service Code
|
APR-DRG 1693
|
| Min. Negotiated Rate |
$33,843.38 |
| Max. Negotiated Rate |
$33,843.38 |
| Rate for Payer: IEHP Medi-Cal |
$33,843.38
|
|
|
MAJOR BILIARY TRACT PROCEDURES
|
Facility
IP
|
$23,408.90
|
|
|
Service Code
|
APR-DRG 2613
|
| Min. Negotiated Rate |
$23,408.90 |
| Max. Negotiated Rate |
$23,408.90 |
| Rate for Payer: IEHP Medi-Cal |
$23,408.90
|
|
|
MAJOR BILIARY TRACT PROCEDURES
|
Facility
IP
|
$44,588.25
|
|
|
Service Code
|
APR-DRG 2614
|
| Min. Negotiated Rate |
$44,588.25 |
| Max. Negotiated Rate |
$44,588.25 |
| Rate for Payer: IEHP Medi-Cal |
$44,588.25
|
|
|
MAJOR BILIARY TRACT PROCEDURES
|
Facility
IP
|
$12,910.76
|
|
|
Service Code
|
APR-DRG 2611
|
| Min. Negotiated Rate |
$12,910.76 |
| Max. Negotiated Rate |
$12,910.76 |
| Rate for Payer: IEHP Medi-Cal |
$12,910.76
|
|
|
MAJOR BILIARY TRACT PROCEDURES
|
Facility
IP
|
$16,895.33
|
|
|
Service Code
|
APR-DRG 2612
|
| Min. Negotiated Rate |
$16,895.33 |
| Max. Negotiated Rate |
$16,895.33 |
| Rate for Payer: IEHP Medi-Cal |
$16,895.33
|
|
|
MAJOR BLADDER PROCEDURES
|
Facility
IP
|
$19,940.70
|
|
|
Service Code
|
APR-DRG 4412
|
| Min. Negotiated Rate |
$19,940.70 |
| Max. Negotiated Rate |
$19,940.70 |
| Rate for Payer: IEHP Medi-Cal |
$19,940.70
|
|
|
MAJOR BLADDER PROCEDURES
|
Facility
IP
|
$26,075.23
|
|
|
Service Code
|
APR-DRG 4413
|
| Min. Negotiated Rate |
$26,075.23 |
| Max. Negotiated Rate |
$26,075.23 |
| Rate for Payer: IEHP Medi-Cal |
$26,075.23
|
|
