|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$45,863.56
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$34,226.54 |
| Max. Negotiated Rate |
$45,863.56 |
| Rate for Payer: EPIC Health Plan Medicare |
$34,226.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34,226.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$39,360.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$45,863.56
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$18,303.58
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$13,659.39 |
| Max. Negotiated Rate |
$18,303.58 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,659.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,659.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,708.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,303.58
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$41,404.34
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$30,898.76 |
| Max. Negotiated Rate |
$41,404.34 |
| Rate for Payer: EPIC Health Plan Medicare |
$30,898.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30,898.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$35,533.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41,404.34
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$75,961.81
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$56,687.92 |
| Max. Negotiated Rate |
$75,961.81 |
| Rate for Payer: EPIC Health Plan Medicare |
$56,687.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$56,687.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65,191.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$75,961.81
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$25,368.63
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$18,931.81 |
| Max. Negotiated Rate |
$25,368.63 |
| Rate for Payer: EPIC Health Plan Medicare |
$18,931.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,931.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,771.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,368.63
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$54,006.57
|
|
|
Service Code
|
MSDRG 574
|
| Min. Negotiated Rate |
$40,303.41 |
| Max. Negotiated Rate |
$54,006.57 |
| Rate for Payer: EPIC Health Plan Medicare |
$40,303.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$40,303.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$46,348.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$54,006.57
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$101,301.39
|
|
|
Service Code
|
MSDRG 573
|
| Min. Negotiated Rate |
$75,598.05 |
| Max. Negotiated Rate |
$101,301.39 |
| Rate for Payer: EPIC Health Plan Medicare |
$75,598.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$75,598.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$86,937.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101,301.39
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$28,295.36
|
|
|
Service Code
|
MSDRG 575
|
| Min. Negotiated Rate |
$21,115.94 |
| Max. Negotiated Rate |
$28,295.36 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,115.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,115.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,283.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,295.36
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$28,247.76
|
|
|
Service Code
|
MSDRG 623
|
| Min. Negotiated Rate |
$21,080.42 |
| Max. Negotiated Rate |
$28,247.76 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,080.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,080.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,242.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,247.76
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$55,354.78
|
|
|
Service Code
|
MSDRG 622
|
| Min. Negotiated Rate |
$41,309.54 |
| Max. Negotiated Rate |
$55,354.78 |
| Rate for Payer: EPIC Health Plan Medicare |
$41,309.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$41,309.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47,505.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55,354.78
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$19,925.10
|
|
|
Service Code
|
MSDRG 624
|
| Min. Negotiated Rate |
$14,869.48 |
| Max. Negotiated Rate |
$19,925.10 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,869.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,869.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,099.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19,925.10
|
|
|
SKIN GRAFTS FOR INJURIES WITH CC/MCC
|
Facility
|
IP
|
$57,103.76
|
|
|
Service Code
|
MSDRG 904
|
| Min. Negotiated Rate |
$42,614.75 |
| Max. Negotiated Rate |
$57,103.76 |
| Rate for Payer: EPIC Health Plan Medicare |
$42,614.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42,614.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$49,006.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57,103.76
|
|
|
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,479.88
|
|
|
Service Code
|
MSDRG 905
|
| Min. Negotiated Rate |
$17,522.30 |
| Max. Negotiated Rate |
$23,479.88 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,522.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,522.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,150.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,479.88
|
|
|
SKIN ULCERS WITH CC
|
Facility
|
IP
|
$18,917.78
|
|
|
Service Code
|
MSDRG 593
|
| Min. Negotiated Rate |
$14,117.75 |
| Max. Negotiated Rate |
$18,917.78 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,117.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,117.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,235.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,917.78
|
|
|
SKIN ULCERS WITH MCC
|
Facility
|
IP
|
$30,419.02
|
|
|
Service Code
|
MSDRG 592
|
| Min. Negotiated Rate |
$22,700.76 |
| Max. Negotiated Rate |
$30,419.02 |
| Rate for Payer: EPIC Health Plan Medicare |
$22,700.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,700.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$26,105.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,419.02
|
|
|
SKIN ULCERS WITHOUT CC/MCC
|
Facility
|
IP
|
$14,011.72
|
|
|
Service Code
|
MSDRG 594
|
| Min. Negotiated Rate |
$10,456.51 |
| Max. Negotiated Rate |
$14,011.72 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,456.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,456.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,024.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,011.72
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.30
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 9994080443
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 9994080443
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]
|
Facility
|
OP
|
$1,095.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.35 |
| Max. Negotiated Rate |
$931.48 |
| Rate for Payer: Adventist Health Commercial |
$219.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$677.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$931.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$602.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$821.89
|
| Rate for Payer: Blue Shield of California Commercial |
$668.47
|
| Rate for Payer: Blue Shield of California EPN |
$534.78
|
| Rate for Payer: Cash Price |
$493.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$504.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$931.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$931.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$931.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$701.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$507.38
|
| Rate for Payer: Heritage Provider Network Senior |
$507.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$522.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$198.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$767.10
|
| Rate for Payer: Multiplan Commercial |
$821.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$438.34
|
| Rate for Payer: TriValley Medical Group Senior |
$438.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$395.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$362.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$931.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$931.48
|
| Rate for Payer: Vantage Medical Group Senior |
$931.48
|
|
|
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]
|
Facility
|
IP
|
$1,095.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.35 |
| Max. Negotiated Rate |
$821.89 |
| Rate for Payer: Adventist Health Commercial |
$219.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$705.73
|
| Rate for Payer: Cash Price |
$493.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$504.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$591.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$507.38
|
| Rate for Payer: Heritage Provider Network Senior |
$507.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$198.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$273.96
|
| Rate for Payer: Multiplan Commercial |
$821.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$395.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$362.84
|
|
|
SODIUM BENZOATE (BULK) POWDER [7305]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 3877905518
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
