|
COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION [92854]
|
Facility
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
|
|
COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]
|
Facility
OP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$5.96 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.77
|
| Rate for Payer: Blue Shield of California Commercial |
$2.53
|
| Rate for Payer: Blue Shield of California EPN |
$2.53
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.67
|
| Rate for Payer: Dignity Health Senior |
$2.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1.43
|
| Rate for Payer: Humana Medicare |
$2.43
|
| Rate for Payer: IEHP Medicare Advantage |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.06
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.67
|
| Rate for Payer: TriValley Medical Group Senior |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION [92855]
|
Facility
IP
|
$3.08
|
|
|
Service Code
|
CPT J7189
|
| Hospital Charge Code |
ERX92855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Adventist Health Commercial |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.12
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.03
|
|
|
COBICISTAT 150 MG TABLET [207759]
|
Facility
IP
|
$11.33
|
|
|
Service Code
|
NDC 61958-1401-1
|
| Hospital Charge Code |
ERX207759
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.78
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.67
|
| Rate for Payer: Heritage Provider Network Senior |
$7.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$8.50
|
|
|
COBICISTAT 150 MG TABLET [207759]
|
Facility
OP
|
$11.33
|
|
|
Service Code
|
NDC 61958-1401-1
|
| Hospital Charge Code |
ERX207759
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.50
|
| Rate for Payer: Blue Shield of California Commercial |
$7.04
|
| Rate for Payer: Blue Shield of California EPN |
$6.65
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.63
|
| Rate for Payer: Dignity Health Senior |
$9.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.01
|
| Rate for Payer: Heritage Provider Network Senior |
$7.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.83
|
| Rate for Payer: Multiplan Commercial |
$8.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.63
|
| Rate for Payer: Vantage Medical Group Senior |
$9.63
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
OP
|
$73.50
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$62.48 |
| Rate for Payer: Adventist Health Commercial |
$14.70
|
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$62.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$56.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$49.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: Blue Shield of California Commercial |
$41.08
|
| Rate for Payer: Blue Shield of California Commercial |
$45.64
|
| Rate for Payer: Blue Shield of California EPN |
$38.83
|
| Rate for Payer: Blue Shield of California EPN |
$43.14
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$56.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.23
|
| Rate for Payer: Dignity Health Senior |
$62.48
|
| Rate for Payer: Dignity Health Senior |
$56.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.63
|
| Rate for Payer: Heritage Provider Network Senior |
$30.63
|
| Rate for Payer: Heritage Provider Network Senior |
$34.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$55.12
|
| Rate for Payer: Multiplan Commercial |
$49.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.48
|
| Rate for Payer: Vantage Medical Group Senior |
$56.23
|
| Rate for Payer: Vantage Medical Group Senior |
$62.48
|
|
|
COCAINE 4 % NASAL SOLUTION [221651]
|
Facility
IP
|
$73.50
|
|
|
Service Code
|
CPT C9046
|
| Hospital Charge Code |
1734001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$55.12 |
| Rate for Payer: Adventist Health Commercial |
$14.70
|
| Rate for Payer: Adventist Health Commercial |
$13.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$45.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.49
|
| Rate for Payer: Cash Price |
$29.77
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.76
|
| Rate for Payer: Heritage Provider Network Senior |
$44.78
|
| Rate for Payer: Heritage Provider Network Senior |
$49.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.38
|
| Rate for Payer: Multiplan Commercial |
$49.61
|
| Rate for Payer: Multiplan Commercial |
$55.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$24.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.56
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
IP
|
$6,272.82
|
|
|
Service Code
|
APR-DRG 7743
|
| Min. Negotiated Rate |
$6,272.82 |
| Max. Negotiated Rate |
$6,272.82 |
| Rate for Payer: IEHP Medi-Cal |
$6,272.82
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
IP
|
$14,691.63
|
|
|
Service Code
|
APR-DRG 7744
|
| Min. Negotiated Rate |
$14,691.63 |
| Max. Negotiated Rate |
$14,691.63 |
| Rate for Payer: IEHP Medi-Cal |
$14,691.63
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
IP
|
$3,447.32
|
|
|
Service Code
|
APR-DRG 7742
|
| Min. Negotiated Rate |
$3,447.32 |
| Max. Negotiated Rate |
$3,447.32 |
| Rate for Payer: IEHP Medi-Cal |
$3,447.32
|
|
|
COCAINE ABUSE AND DEPENDENCE
|
Facility
IP
|
$2,844.41
|
|
|
Service Code
|
APR-DRG 7741
|
| Min. Negotiated Rate |
$2,844.41 |
| Max. Negotiated Rate |
$2,844.41 |
| Rate for Payer: IEHP Medi-Cal |
$2,844.41
|
|
|
Cochlear device implantation, with or without mastoidectomy
|
Facility
OP
|
$79,608.38
|
|
|
Service Code
|
CPT 69930
|
| Min. Negotiated Rate |
$351.95 |
| Max. Negotiated Rate |
$79,608.38 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$62,848.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46,089.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41,899.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62,848.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$46,089.06
|
| Rate for Payer: Dignity Health Senior |
$41,899.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$41,899.15
|
| Rate for Payer: Humana Medicare |
$41,899.15
|
| Rate for Payer: IEHP Medi-Cal |
$351.95
|
| Rate for Payer: IEHP Medicare Advantage |
$41,899.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$79,608.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49,441.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52,792.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52,792.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$46,089.06
|
| Rate for Payer: TriValley Medical Group Senior |
$41,899.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62,848.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46,089.06
|
| Rate for Payer: Vantage Medical Group Senior |
$41,899.15
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE4SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09PD0SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE45Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE0SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE46Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09PD7SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HD4SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE05Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE06Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE35Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HD45Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HD46Z
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
|
Cochlear Implants (IP) - #2077
|
Facility
IP
|
$27,390.00
|
|
|
Service Code
|
ICD 09HE3SZ
|
| Min. Negotiated Rate |
$27,390.00 |
| Max. Negotiated Rate |
$27,390.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,390.00
|
|
