|
CONJUGATED ESTROGENS 0.625 MG TABLET [9974]
|
Facility
OP
|
$8.05
|
|
|
Service Code
|
NDC 0046-1102-81
|
| Hospital Charge Code |
1710519
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: Adventist Health Commercial |
$1.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.04
|
| Rate for Payer: Blue Shield of California Commercial |
$5.00
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.84
|
| Rate for Payer: Dignity Health Senior |
$6.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.98
|
| Rate for Payer: Heritage Provider Network Senior |
$4.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.01
|
| Rate for Payer: Multiplan Commercial |
$6.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.84
|
| Rate for Payer: Vantage Medical Group Senior |
$6.84
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
OP
|
$428.80
|
|
|
Service Code
|
CPT J1410
|
| Hospital Charge Code |
1720160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.61 |
| Max. Negotiated Rate |
$914.23 |
| Rate for Payer: Adventist Health Commercial |
$85.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$914.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$465.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$409.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$409.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.52
|
| Rate for Payer: Blue Shield of California Commercial |
$347.11
|
| Rate for Payer: Blue Shield of California EPN |
$347.11
|
| Rate for Payer: Cash Price |
$192.96
|
| Rate for Payer: Cash Price |
$192.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$558.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$409.36
|
| Rate for Payer: Dignity Health Senior |
$409.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$274.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$372.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$198.53
|
| Rate for Payer: Heritage Provider Network Senior |
$198.53
|
| Rate for Payer: Humana Medicare |
$372.15
|
| Rate for Payer: IEHP Medi-Cal |
$587.51
|
| Rate for Payer: IEHP Medicare Advantage |
$372.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$707.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$439.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$468.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$468.90
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$409.36
|
| Rate for Payer: TriValley Medical Group Senior |
$372.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$558.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$409.36
|
| Rate for Payer: Vantage Medical Group Senior |
$372.15
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [9972]
|
Facility
IP
|
$428.80
|
|
|
Service Code
|
CPT J1410
|
| Hospital Charge Code |
1720160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.61 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Adventist Health Commercial |
$85.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$294.59
|
| Rate for Payer: Cash Price |
$192.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$197.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$231.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$290.30
|
| Rate for Payer: Heritage Provider Network Senior |
$290.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.20
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$156.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.26
|
|
|
Conjunctivoplasty; with conjunctival graft or extensive rearrangement
|
Facility
OP
|
$7,436.00
|
|
|
Service Code
|
CPT 68320
|
| Min. Negotiated Rate |
$696.95 |
| Max. Negotiated Rate |
$7,436.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: IEHP Medi-Cal |
$696.95
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$10,844.37
|
|
|
Service Code
|
APR-DRG 3463
|
| Min. Negotiated Rate |
$10,844.37 |
| Max. Negotiated Rate |
$10,844.37 |
| Rate for Payer: IEHP Medi-Cal |
$10,844.37
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$22,511.51
|
|
|
Service Code
|
APR-DRG 3464
|
| Min. Negotiated Rate |
$22,511.51 |
| Max. Negotiated Rate |
$22,511.51 |
| Rate for Payer: IEHP Medi-Cal |
$22,511.51
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$5,335.63
|
|
|
Service Code
|
APR-DRG 3461
|
| Min. Negotiated Rate |
$5,335.63 |
| Max. Negotiated Rate |
$5,335.63 |
| Rate for Payer: IEHP Medi-Cal |
$5,335.63
|
|
|
CONNECTIVE TISSUE DISORDERS
|
Facility
IP
|
$7,105.55
|
|
|
Service Code
|
APR-DRG 3462
|
| Min. Negotiated Rate |
$7,105.55 |
| Max. Negotiated Rate |
$7,105.55 |
| Rate for Payer: IEHP Medi-Cal |
$7,105.55
|
|
|
Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy;
|
Facility
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 67880
|
| Min. Negotiated Rate |
$138.81 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: IEHP Medi-Cal |
$138.81
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer prosthesis)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31611
|
| Min. Negotiated Rate |
$1,045.42 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: IEHP Medi-Cal |
$1,045.42
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 42960
|
| Min. Negotiated Rate |
$115.58 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$687.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.18
|
| Rate for Payer: Dignity Health Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$687.44
|
| Rate for Payer: Humana Medicare |
$687.44
|
| Rate for Payer: IEHP Medi-Cal |
$115.58
|
| Rate for Payer: IEHP Medicare Advantage |
$687.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,306.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$811.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$866.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$866.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$756.18
|
| Rate for Payer: TriValley Medical Group Senior |
$687.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$8,891.38
|
|
|
Service Code
|
APR-DRG 3843
|
| Min. Negotiated Rate |
$8,891.38 |
| Max. Negotiated Rate |
$8,891.38 |
| Rate for Payer: IEHP Medi-Cal |
$8,891.38
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$14,905.53
|
|
|
Service Code
|
APR-DRG 3844
|
| Min. Negotiated Rate |
$14,905.53 |
| Max. Negotiated Rate |
$14,905.53 |
| Rate for Payer: IEHP Medi-Cal |
$14,905.53
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$6,102.69
|
|
|
Service Code
|
APR-DRG 3842
|
| Min. Negotiated Rate |
$6,102.69 |
| Max. Negotiated Rate |
$6,102.69 |
| Rate for Payer: IEHP Medi-Cal |
$6,102.69
|
|
|
CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE
|
Facility
IP
|
$4,869.02
|
|
|
Service Code
|
APR-DRG 3841
|
| Min. Negotiated Rate |
$4,869.02 |
| Max. Negotiated Rate |
$4,869.02 |
| Rate for Payer: IEHP Medi-Cal |
$4,869.02
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]
|
Facility
IP
|
$6,180.48
|
|
|
Service Code
|
CPT J9057
|
| Hospital Charge Code |
ERX219718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,118.67 |
| Max. Negotiated Rate |
$4,635.36 |
| Rate for Payer: Adventist Health Commercial |
$1,236.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,245.99
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,843.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,337.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,184.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4,184.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,118.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,545.12
|
| Rate for Payer: Multiplan Commercial |
$4,635.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,253.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,064.90
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]
|
Facility
OP
|
$6,180.48
|
|
|
Service Code
|
CPT J9057
|
| Hospital Charge Code |
ERX219718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.16 |
| Max. Negotiated Rate |
$4,635.36 |
| Rate for Payer: Adventist Health Commercial |
$1,236.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$166.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,245.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$109.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$96.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$96.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.89
|
| Rate for Payer: Blue Shield of California Commercial |
$84.16
|
| Rate for Payer: Blue Shield of California EPN |
$84.16
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Cash Price |
$2,781.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,843.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$131.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.32
|
| Rate for Payer: Dignity Health Senior |
$96.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,955.51
|
| Rate for Payer: EPIC Health Plan Medicare |
$87.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,861.56
|
| Rate for Payer: Heritage Provider Network Senior |
$2,861.56
|
| Rate for Payer: Humana Medicare |
$87.56
|
| Rate for Payer: IEHP Medicare Advantage |
$87.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$166.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,118.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$103.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,545.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$110.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$110.33
|
| Rate for Payer: Multiplan Commercial |
$4,635.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.32
|
| Rate for Payer: TriValley Medical Group Senior |
$87.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,253.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,064.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$131.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.32
|
| Rate for Payer: Vantage Medical Group Senior |
$87.56
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
1715158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| 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 |
$1.95
|
|
|
COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]
|
Facility
OP
|
$2.60
|
|
|
Service Code
|
NDC 9994-0804-25
|
| Hospital Charge Code |
1715158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| 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 |
$1.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994-0804-26
|
| Hospital Charge Code |
1715311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$32,920.12
|
|
|
Service Code
|
APR-DRG 1651
|
| Min. Negotiated Rate |
$32,920.12 |
| Max. Negotiated Rate |
$32,920.12 |
| Rate for Payer: IEHP Medi-Cal |
$32,920.12
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$40,087.34
|
|
|
Service Code
|
APR-DRG 1652
|
| Min. Negotiated Rate |
$40,087.34 |
| Max. Negotiated Rate |
$40,087.34 |
| Rate for Payer: IEHP Medi-Cal |
$40,087.34
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$48,198.74
|
|
|
Service Code
|
APR-DRG 1653
|
| Min. Negotiated Rate |
$48,198.74 |
| Max. Negotiated Rate |
$48,198.74 |
| Rate for Payer: IEHP Medi-Cal |
$48,198.74
|
|
|
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$65,260.20
|
|
|
Service Code
|
APR-DRG 1654
|
| Min. Negotiated Rate |
$65,260.20 |
| Max. Negotiated Rate |
$65,260.20 |
| Rate for Payer: IEHP Medi-Cal |
$65,260.20
|
|
