|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 5789679101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 2438511878
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET [7227]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 2438511878
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$13,076.56
|
|
|
Service Code
|
MSDRG 194
|
| Min. Negotiated Rate |
$9,758.63 |
| Max. Negotiated Rate |
$13,076.56 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,758.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,758.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,222.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,076.56
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$20,884.81
|
|
|
Service Code
|
MSDRG 193
|
| Min. Negotiated Rate |
$15,585.68 |
| Max. Negotiated Rate |
$20,884.81 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,585.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,585.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,923.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,884.81
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$10,352.53
|
|
|
Service Code
|
MSDRG 195
|
| Min. Negotiated Rate |
$7,725.77 |
| Max. Negotiated Rate |
$10,352.53 |
| Rate for Payer: EPIC Health Plan Medicare |
$7,725.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,725.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,884.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,352.53
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0395266116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0395266116
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 3877917791
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 3877917798
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 3877917798
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3172293747
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SIMPLE SYRUP [7242]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 3877917791
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$86,762.84
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$64,748.39 |
| Max. Negotiated Rate |
$86,762.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$64,748.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$64,748.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$74,460.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$86,762.84
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$110,256.71
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$82,281.13 |
| Max. Negotiated Rate |
$110,256.71 |
| Rate for Payer: EPIC Health Plan Medicare |
$82,281.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$82,281.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$94,623.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$110,256.71
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 6808451201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| 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 |
$0.22
|
|
|
SIMVASTATIN 20 MG TABLET [11365]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 6808451201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| 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 |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
IP
|
$156.56
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$117.42 |
| Rate for Payer: Adventist Health Commercial |
$31.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.82
|
| Rate for Payer: Cash Price |
$70.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.49
|
| Rate for Payer: Heritage Provider Network Senior |
$72.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.14
|
| Rate for Payer: Multiplan Commercial |
$117.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.84
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
OP
|
$156.56
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$133.08 |
| Rate for Payer: Adventist Health Commercial |
$31.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$133.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$117.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$130.41
|
| Rate for Payer: Blue Shield of California Commercial |
$126.62
|
| Rate for Payer: Blue Shield of California EPN |
$126.62
|
| Rate for Payer: Cash Price |
$70.45
|
| Rate for Payer: Cash Price |
$70.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$133.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$133.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$133.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$100.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.49
|
| Rate for Payer: Heritage Provider Network Senior |
$72.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$74.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$109.59
|
| Rate for Payer: Multiplan Commercial |
$117.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.62
|
| Rate for Payer: TriValley Medical Group Senior |
$62.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$133.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$133.08
|
| Rate for Payer: Vantage Medical Group Senior |
$133.08
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$62,438.25
|
|
|
Service Code
|
MSDRG 402
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$62,438.25 |
| Rate for Payer: EPIC Health Plan Medicare |
$46,595.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$46,595.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$53,585.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$62,438.25
|
|
|
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE
|
Facility
|
IP
|
$82,540.07
|
|
|
Service Code
|
MSDRG 450
|
| Min. Negotiated Rate |
$61,597.07 |
| Max. Negotiated Rate |
$82,540.07 |
| Rate for Payer: EPIC Health Plan Medicare |
$61,597.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$61,597.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70,836.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$82,540.07
|
|
|
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC
|
Facility
|
IP
|
$50,305.89
|
|
|
Service Code
|
MSDRG 451
|
| Min. Negotiated Rate |
$37,541.71 |
| Max. Negotiated Rate |
$50,305.89 |
| Rate for Payer: EPIC Health Plan Medicare |
$37,541.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37,541.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43,172.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$50,305.89
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$34,022.98
|
|
|
Service Code
|
MSDRG 135
|
| Min. Negotiated Rate |
$25,390.28 |
| Max. Negotiated Rate |
$34,022.98 |
| Rate for Payer: EPIC Health Plan Medicare |
$25,390.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25,390.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29,198.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34,022.98
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$16,291.99
|
|
|
Service Code
|
MSDRG 136
|
| Min. Negotiated Rate |
$12,158.20 |
| Max. Negotiated Rate |
$16,291.99 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,158.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,158.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,981.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,291.99
|
|
