|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 5026875515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 5026875515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 6808453911
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 6808453911
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6586212701
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 3172253101
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 3172253101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| 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
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6586212701
|
| 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
|
|
|
TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY
|
Facility
|
OP
|
$14,773.56
|
|
|
Service Code
|
CPT 60220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,158.00 |
| Max. Negotiated Rate |
$14,773.56 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,663.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,553.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,775.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,829.24
|
| Rate for Payer: Blue Shield of California EPN |
$8,674.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,663.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,553.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,775.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,775.56
|
| Rate for Payer: Heritage Provider Network Senior |
$9,563.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,775.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14,773.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,941.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,419.25
|
| Rate for Payer: Multiplan WC |
$11,811.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,553.12
|
| Rate for Payer: TriValley Medical Group Senior |
$8,553.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,160.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,956.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,663.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,553.12
|
| Rate for Payer: Vantage Medical Group Senior |
$7,775.56
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994081636
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$374.25 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$321.36
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.82
|
| Rate for Payer: Heritage Provider Network Senior |
$337.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994081636
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$308.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$249.60
|
| Rate for Payer: Blue Shield of California Commercial |
$304.39
|
| Rate for Payer: Blue Shield of California EPN |
$243.51
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.88
|
| Rate for Payer: Heritage Provider Network Senior |
$308.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$238.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$199.60
|
| Rate for Payer: TriValley Medical Group Senior |
$199.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$249.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
NDC 9999196140
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$308.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$249.60
|
| Rate for Payer: Blue Shield of California Commercial |
$304.39
|
| Rate for Payer: Blue Shield of California EPN |
$243.51
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.88
|
| Rate for Payer: Heritage Provider Network Senior |
$308.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$238.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$349.30
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$199.60
|
| Rate for Payer: TriValley Medical Group Senior |
$199.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$249.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$249.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
|
TPN: NICU STARTER [196140]
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
NDC 9999196140
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$374.25 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$321.36
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.82
|
| Rate for Payer: Heritage Provider Network Senior |
$337.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS POWDER FOR SOLUTION [211543]
|
Facility
|
IP
|
$4,737.11
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$857.42 |
| Max. Negotiated Rate |
$3,552.83 |
| Rate for Payer: Adventist Health Commercial |
$947.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,050.70
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,179.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,558.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,193.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2,193.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$857.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,184.28
|
| Rate for Payer: Multiplan Commercial |
$3,552.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,711.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,568.46
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS POWDER FOR SOLUTION [211543]
|
Facility
|
OP
|
$4,737.11
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$351.70 |
| Max. Negotiated Rate |
$3,552.83 |
| Rate for Payer: Adventist Health Commercial |
$947.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,927.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$615.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$451.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$410.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$654.57
|
| Rate for Payer: Blue Shield of California Commercial |
$351.70
|
| Rate for Payer: Blue Shield of California EPN |
$351.70
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cash Price |
$2,131.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,179.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$513.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$451.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$451.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,031.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$410.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,193.28
|
| Rate for Payer: Heritage Provider Network Senior |
$2,193.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$410.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,259.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$857.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$472.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,184.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$550.04
|
| Rate for Payer: Multiplan Commercial |
$3,552.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,894.84
|
| Rate for Payer: TriValley Medical Group Senior |
$1,894.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,711.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,568.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$513.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$451.53
|
| Rate for Payer: Vantage Medical Group Senior |
$451.53
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.61
|
|
|
TRACE ELEMENT PEDI CR-CU-MN-ZN 1 MCG-0.1 MG-25 MCG-1 MG/ML INTRAVENOUS [18266]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.65
|
| Rate for Payer: Blue Shield of California Commercial |
$2.96
|
| Rate for Payer: Blue Shield of California EPN |
$2.37
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.40
|
| Rate for Payer: Multiplan Commercial |
$3.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.94
|
| Rate for Payer: TriValley Medical Group Senior |
$1.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.13
|
| Rate for Payer: Vantage Medical Group Senior |
$4.13
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
|
|
TRACE ELEMENTS CHOLESTASIS [4080051]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
|
|
TRACE ELEMENTS FULL TERM [4080053]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS PRETERM [4080052]
|
Facility
|
OP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.72
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
TRACE ELEMENTS PRETERM [4080052]
|
Facility
|
IP
|
$6.30
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Senior |
$2.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.09
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC
|
Facility
|
IP
|
$65,440.24
|
|
|
Service Code
|
MSDRG 012
|
| Min. Negotiated Rate |
$48,836.00 |
| Max. Negotiated Rate |
$65,440.24 |
| Rate for Payer: EPIC Health Plan Medicare |
$48,836.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48,836.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56,161.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$65,440.24
|
|
|
TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC
|
Facility
|
IP
|
$84,451.85
|
|
|
Service Code
|
MSDRG 011
|
| Min. Negotiated Rate |
$63,023.77 |
| Max. Negotiated Rate |
$84,451.85 |
| Rate for Payer: EPIC Health Plan Medicare |
$63,023.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63,023.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$72,477.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84,451.85
|
|
