|
UREA 10 % LOTION [19779]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| Hospital Charge Code |
NDG19779A
|
|
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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
UREA 10 % LOTION [19779]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 5898060880
|
| Hospital Charge Code |
NDG19779A
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
OP
|
$4.20
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
ERX218764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.61
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Senior |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Senior |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
UREA 15 GRAM ORAL POWDER PACKET [218764]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
NDC 6253000011
|
| Hospital Charge Code |
ERX218764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 536110945
|
| Hospital Charge Code |
NDG19776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA 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: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 536110945
|
| Hospital Charge Code |
NDG19776
|
|
Hospital Revenue Code
|
259
|
| 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: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 884044904
|
| Hospital Charge Code |
NDG19776B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
UREA 20 % TOPICAL CREAM [19776]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 884044904
|
| Hospital Charge Code |
NDG19776B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$23,181.08
|
|
|
Service Code
|
APR-DRG 4464
|
| Min. Negotiated Rate |
$23,181.08 |
| Max. Negotiated Rate |
$23,181.08 |
| Rate for Payer: IEHP Medi-Cal |
$23,181.08
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$7,306.51
|
|
|
Service Code
|
APR-DRG 4461
|
| Min. Negotiated Rate |
$7,306.51 |
| Max. Negotiated Rate |
$7,306.51 |
| Rate for Payer: IEHP Medi-Cal |
$7,306.51
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$8,897.35
|
|
|
Service Code
|
APR-DRG 4462
|
| Min. Negotiated Rate |
$8,897.35 |
| Max. Negotiated Rate |
$8,897.35 |
| Rate for Payer: IEHP Medi-Cal |
$8,897.35
|
|
|
URETHRAL AND TRANSURETHRAL PROCEDURES
|
Facility
IP
|
$13,987.24
|
|
|
Service Code
|
APR-DRG 4463
|
| Min. Negotiated Rate |
$13,987.24 |
| Max. Negotiated Rate |
$13,987.24 |
| Rate for Payer: IEHP Medi-Cal |
$13,987.24
|
|
|
Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 53500
|
| Min. Negotiated Rate |
$600.44 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$600.44
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Urethromeatoplasty, with mucosal advancement
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 53450
|
| Min. Negotiated Rate |
$284.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$284.00
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type)
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 53400
|
| Min. Negotiated Rate |
$658.04 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$658.04
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 54308
|
| Min. Negotiated Rate |
$1,026.84 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$1,026.84
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Urethroplasty, reconstruction of female urethra
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 53430
|
| Min. Negotiated Rate |
$921.13 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$921.13
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$4,367.60
|
|
|
Service Code
|
APR-DRG 4651
|
| Min. Negotiated Rate |
$4,367.60 |
| Max. Negotiated Rate |
$4,367.60 |
| Rate for Payer: IEHP Medi-Cal |
$4,367.60
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$5,366.47
|
|
|
Service Code
|
APR-DRG 4652
|
| Min. Negotiated Rate |
$5,366.47 |
| Max. Negotiated Rate |
$5,366.47 |
| Rate for Payer: IEHP Medi-Cal |
$5,366.47
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$8,881.43
|
|
|
Service Code
|
APR-DRG 4653
|
| Min. Negotiated Rate |
$8,881.43 |
| Max. Negotiated Rate |
$8,881.43 |
| Rate for Payer: IEHP Medi-Cal |
$8,881.43
|
|
|
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION
|
Facility
IP
|
$15,427.85
|
|
|
Service Code
|
APR-DRG 4654
|
| Min. Negotiated Rate |
$15,427.85 |
| Max. Negotiated Rate |
$15,427.85 |
| Rate for Payer: IEHP Medi-Cal |
$15,427.85
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$1.70
|
|
|
Service Code
|
NDC 49884-412-01
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.75
|
| Rate for Payer: Heritage Provider Network Senior |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
IP
|
$4.20
|
|
|
Service Code
|
NDC 60687-527-11
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.89
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.84
|
| Rate for Payer: Heritage Provider Network Senior |
$2.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
URSODIOL 250 MG TABLET [22660]
|
Facility
OP
|
$2.58
|
|
|
Service Code
|
NDC 68001-377-00
|
| Hospital Charge Code |
1712240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$1.60
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.19
|
| Rate for Payer: Dignity Health Senior |
$2.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.19
|
| Rate for Payer: Vantage Medical Group Senior |
$2.19
|
|
