|
URSODIOL ORAL SUSPENSION COMPOUND 60 MG/ML [4080354]
|
Facility
OP
|
$1.50
|
|
|
Service Code
|
NDC 9994-0803-54
|
| Hospital Charge Code |
1715942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.28
|
| Rate for Payer: Dignity Health Senior |
$1.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: Vantage Medical Group Senior |
$1.28
|
|
|
Use of ophthalmic endoscope (List separately in addition to code for primary procedure)
|
Facility
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 66990
|
| Min. Negotiated Rate |
$72.77 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: IEHP Medi-Cal |
$72.77
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
OP
|
$88.99
|
|
|
Service Code
|
CPT J3358
|
| Hospital Charge Code |
NDG215734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.62 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Adventist Health Commercial |
$17.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$31.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.32
|
| Rate for Payer: Blue Shield of California Commercial |
$14.54
|
| Rate for Payer: Blue Shield of California EPN |
$14.54
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.88
|
| Rate for Payer: Dignity Health Senior |
$13.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.20
|
| Rate for Payer: Heritage Provider Network Senior |
$41.20
|
| Rate for Payer: Humana Medicare |
$12.62
|
| Rate for Payer: IEHP Medi-Cal |
$26.64
|
| Rate for Payer: IEHP Medicare Advantage |
$12.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.90
|
| Rate for Payer: Multiplan Commercial |
$66.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.88
|
| Rate for Payer: Vantage Medical Group Senior |
$12.62
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [215734]
|
Facility
IP
|
$88.99
|
|
|
Service Code
|
CPT J3358
|
| Hospital Charge Code |
NDG215734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Adventist Health Commercial |
$17.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.14
|
| Rate for Payer: Cash Price |
$40.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.25
|
| Rate for Payer: Heritage Provider Network Senior |
$60.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.25
|
| Rate for Payer: Multiplan Commercial |
$66.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.73
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
IP
|
$31,820.40
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
NDG108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,759.49 |
| Max. Negotiated Rate |
$23,865.30 |
| Rate for Payer: Adventist Health Commercial |
$6,364.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21,860.61
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,637.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$17,183.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$21,542.41
|
| Rate for Payer: Heritage Provider Network Senior |
$21,542.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,759.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,955.10
|
| Rate for Payer: Multiplan Commercial |
$23,865.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11,601.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,631.20
|
|
|
USTEKINUMAB 90 MG/ML SUBCUTANEOUS SYRINGE [108054]
|
Facility
OP
|
$31,820.40
|
|
|
Service Code
|
CPT J3357
|
| Hospital Charge Code |
NDG108054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$153.96 |
| Max. Negotiated Rate |
$23,865.30 |
| Rate for Payer: Adventist Health Commercial |
$6,364.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$378.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21,860.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$192.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$169.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$169.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$232.29
|
| Rate for Payer: Blue Shield of California Commercial |
$288.97
|
| Rate for Payer: Blue Shield of California EPN |
$288.97
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Cash Price |
$14,319.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,637.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$230.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.35
|
| Rate for Payer: Dignity Health Senior |
$169.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$20,365.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$153.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,732.85
|
| Rate for Payer: Heritage Provider Network Senior |
$14,732.85
|
| Rate for Payer: Humana Medicare |
$153.96
|
| Rate for Payer: IEHP Medi-Cal |
$247.14
|
| Rate for Payer: IEHP Medicare Advantage |
$153.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$292.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,759.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$181.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,955.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$193.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$193.98
|
| Rate for Payer: Multiplan Commercial |
$23,865.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$169.35
|
| Rate for Payer: TriValley Medical Group Senior |
$153.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11,601.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,631.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$230.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.35
|
| Rate for Payer: Vantage Medical Group Senior |
$153.96
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
IP
|
$31,459.61
|
|
|
Service Code
|
APR-DRG 5194
|
| Min. Negotiated Rate |
$31,459.61 |
| Max. Negotiated Rate |
$31,459.61 |
| Rate for Payer: IEHP Medi-Cal |
$31,459.61
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
IP
|
$8,006.93
|
|
|
Service Code
|
APR-DRG 5191
|
| Min. Negotiated Rate |
$8,006.93 |
| Max. Negotiated Rate |
$8,006.93 |
| Rate for Payer: IEHP Medi-Cal |
$8,006.93
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
IP
|
$10,174.80
|
|
|
Service Code
|
APR-DRG 5192
|
| Min. Negotiated Rate |
$10,174.80 |
| Max. Negotiated Rate |
$10,174.80 |
| Rate for Payer: IEHP Medi-Cal |
$10,174.80
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA
|
Facility
IP
|
$16,446.63
|
|
|
Service Code
|
APR-DRG 5193
|
| Min. Negotiated Rate |
$16,446.63 |
| Max. Negotiated Rate |
$16,446.63 |
| Rate for Payer: IEHP Medi-Cal |
$16,446.63
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
IP
|
$8,466.56
|
|
|
Service Code
|
APR-DRG 5131
|
| Min. Negotiated Rate |
$8,466.56 |
| Max. Negotiated Rate |
$8,466.56 |
| Rate for Payer: IEHP Medi-Cal |
$8,466.56
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
IP
|
$26,278.19
|
|
|
Service Code
|
APR-DRG 5134
|
| Min. Negotiated Rate |
$26,278.19 |
| Max. Negotiated Rate |
$26,278.19 |
| Rate for Payer: IEHP Medi-Cal |
$26,278.19
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
IP
|
$16,191.93
|
|
|
Service Code
|
APR-DRG 5133
|
| Min. Negotiated Rate |
$16,191.93 |
| Max. Negotiated Rate |
$16,191.93 |
| Rate for Payer: IEHP Medi-Cal |
$16,191.93
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
|
Facility
IP
|
$10,191.71
|
|
|
Service Code
|
APR-DRG 5132
|
| Min. Negotiated Rate |
$10,191.71 |
| Max. Negotiated Rate |
$10,191.71 |
| Rate for Payer: IEHP Medi-Cal |
$10,191.71
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY
|
Facility
IP
|
$34,953.68
|
|
|
Service Code
|
APR-DRG 5124
|
| Min. Negotiated Rate |
$34,953.68 |
| Max. Negotiated Rate |
$34,953.68 |
| Rate for Payer: IEHP Medi-Cal |
$34,953.68
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY
|
Facility
IP
|
$10,956.79
|
|
|
Service Code
|
APR-DRG 5121
|
| Min. Negotiated Rate |
$10,956.79 |
| Max. Negotiated Rate |
$10,956.79 |
| Rate for Payer: IEHP Medi-Cal |
$10,956.79
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY
|
Facility
IP
|
$12,963.50
|
|
|
Service Code
|
APR-DRG 5122
|
| Min. Negotiated Rate |
$12,963.50 |
| Max. Negotiated Rate |
$12,963.50 |
| Rate for Payer: IEHP Medi-Cal |
$12,963.50
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY
|
Facility
IP
|
$20,401.34
|
|
|
Service Code
|
APR-DRG 5123
|
| Min. Negotiated Rate |
$20,401.34 |
| Max. Negotiated Rate |
$20,401.34 |
| Rate for Payer: IEHP Medi-Cal |
$20,401.34
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY
|
Facility
IP
|
$21,372.36
|
|
|
Service Code
|
APR-DRG 5113
|
| Min. Negotiated Rate |
$21,372.36 |
| Max. Negotiated Rate |
$21,372.36 |
| Rate for Payer: IEHP Medi-Cal |
$21,372.36
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY
|
Facility
IP
|
$39,363.06
|
|
|
Service Code
|
APR-DRG 5114
|
| Min. Negotiated Rate |
$39,363.06 |
| Max. Negotiated Rate |
$39,363.06 |
| Rate for Payer: IEHP Medi-Cal |
$39,363.06
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY
|
Facility
IP
|
$14,511.55
|
|
|
Service Code
|
APR-DRG 5112
|
| Min. Negotiated Rate |
$14,511.55 |
| Max. Negotiated Rate |
$14,511.55 |
| Rate for Payer: IEHP Medi-Cal |
$14,511.55
|
|
|
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY
|
Facility
IP
|
$11,949.69
|
|
|
Service Code
|
APR-DRG 5111
|
| Min. Negotiated Rate |
$11,949.69 |
| Max. Negotiated Rate |
$11,949.69 |
| Rate for Payer: IEHP Medi-Cal |
$11,949.69
|
|
|
VAGINAL DELIVERY
|
Facility
IP
|
$7,145.25
|
|
|
Service Code
|
APR-DRG 5604
|
| Min. Negotiated Rate |
$7,145.25 |
| Max. Negotiated Rate |
$7,145.25 |
| Rate for Payer: IEHP Medi-Cal |
$7,145.25
|
|
|
VAGINAL DELIVERY
|
Facility
IP
|
$3,541.83
|
|
|
Service Code
|
APR-DRG 5602
|
| Min. Negotiated Rate |
$3,541.83 |
| Max. Negotiated Rate |
$3,541.83 |
| Rate for Payer: IEHP Medi-Cal |
$3,541.83
|
|
|
VAGINAL DELIVERY
|
Facility
IP
|
$3,102.08
|
|
|
Service Code
|
APR-DRG 5601
|
| Min. Negotiated Rate |
$3,102.08 |
| Max. Negotiated Rate |
$3,102.08 |
| Rate for Payer: IEHP Medi-Cal |
$3,102.08
|
|
