|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Adventist Health Commercial |
$16.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.82
|
| Rate for Payer: Blue Shield of California Commercial |
$52.01
|
| Rate for Payer: Blue Shield of California EPN |
$49.17
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.20
|
| Rate for Payer: Dignity Health Senior |
$71.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$53.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.85
|
| Rate for Payer: Heritage Provider Network Senior |
$51.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.94
|
| Rate for Payer: Multiplan Commercial |
$62.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.50
|
| Rate for Payer: TriValley Medical Group Senior |
$33.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.20
|
| Rate for Payer: Vantage Medical Group Senior |
$71.20
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$4.62
|
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.87
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$15.64
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$18.56 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Adventist Health Commercial |
$4.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.24
|
| Rate for Payer: TriValley Medical Group Senior |
$9.24
|
| Rate for Payer: TriValley Medical Group Senior |
$1.15
|
| Rate for Payer: TriValley Medical Group Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$18.56 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Senior |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.38
|
| Rate for Payer: Heritage Provider Network Senior |
$9.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
IP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.38
|
| Rate for Payer: Heritage Provider Network Senior |
$9.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
OP
|
$13.86
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$18.56 |
| Rate for Payer: Adventist Health Commercial |
$2.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.42
|
| Rate for Payer: Heritage Provider Network Senior |
$6.42
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$10.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.54
|
| Rate for Payer: TriValley Medical Group Senior |
$5.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$4.62
|
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.87
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$1.95
|
| Rate for Payer: Heritage Provider Network Senior |
$15.64
|
| Rate for Payer: Heritage Provider Network Senior |
$6.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
|
|
FOSPHENYTOIN 50 MG PE/ML IV INJECTION SOLUTION WRAP [408056880]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
CPT Q2009
|
| Hospital Charge Code |
1720991
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$18.56 |
| Rate for Payer: Adventist Health Commercial |
$1.80
|
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Adventist Health Commercial |
$4.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.56
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Blue Shield of California EPN |
$4.73
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cash Price |
$4.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: Dignity Health Senior |
$5.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.78
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$4.17
|
| Rate for Payer: Heritage Provider Network Senior |
$10.70
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Humana Medicare |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.05
|
| Rate for Payer: Multiplan Commercial |
$17.32
|
| Rate for Payer: Multiplan Commercial |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$6.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.24
|
| Rate for Payer: TriValley Medical Group Senior |
$9.24
|
| Rate for Payer: TriValley Medical Group Senior |
$1.15
|
| Rate for Payer: TriValley Medical Group Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.28
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4.80
|
|
|
Fracture nasal inferior turbinate(s), therapeutic
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 30930
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$118.48
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$10,756.81
|
|
|
Service Code
|
APR-DRG 3404
|
| Min. Negotiated Rate |
$10,756.81 |
| Max. Negotiated Rate |
$10,756.81 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,756.81
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$5,128.69
|
|
|
Service Code
|
APR-DRG 3402
|
| Min. Negotiated Rate |
$5,128.69 |
| Max. Negotiated Rate |
$5,128.69 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,128.69
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$4,125.84
|
|
|
Service Code
|
APR-DRG 3401
|
| Min. Negotiated Rate |
$4,125.84 |
| Max. Negotiated Rate |
$4,125.84 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,125.84
|
|
|
FRACTURE OF FEMUR
|
Facility
|
IP
|
$7,312.49
|
|
|
Service Code
|
APR-DRG 3403
|
| Min. Negotiated Rate |
$7,312.49 |
| Max. Negotiated Rate |
$7,312.49 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,312.49
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$5,437.11
|
|
|
Service Code
|
APR-DRG 3412
|
| Min. Negotiated Rate |
$5,437.11 |
| Max. Negotiated Rate |
$5,437.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,437.11
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$4,433.26
|
|
|
Service Code
|
APR-DRG 3411
|
| Min. Negotiated Rate |
$4,433.26 |
| Max. Negotiated Rate |
$4,433.26 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,433.26
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$6,927.47
|
|
|
Service Code
|
APR-DRG 3413
|
| Min. Negotiated Rate |
$6,927.47 |
| Max. Negotiated Rate |
$6,927.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,927.47
|
|
|
FRACTURE OF PELVIS OR DISLOCATION OF HIP
|
Facility
|
IP
|
$12,926.68
|
|
|
Service Code
|
APR-DRG 3414
|
| Min. Negotiated Rate |
$12,926.68 |
| Max. Negotiated Rate |
$12,926.68 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,926.68
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$4,446.19
|
|
|
Service Code
|
APR-DRG 3421
|
| Min. Negotiated Rate |
$4,446.19 |
| Max. Negotiated Rate |
$4,446.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,446.19
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$5,988.28
|
|
|
Service Code
|
APR-DRG 3422
|
| Min. Negotiated Rate |
$5,988.28 |
| Max. Negotiated Rate |
$5,988.28 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,988.28
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$8,346.19
|
|
|
Service Code
|
APR-DRG 3423
|
| Min. Negotiated Rate |
$8,346.19 |
| Max. Negotiated Rate |
$8,346.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,346.19
|
|
|
FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK
|
Facility
|
IP
|
$13,708.67
|
|
|
Service Code
|
APR-DRG 3424
|
| Min. Negotiated Rate |
$13,708.67 |
| Max. Negotiated Rate |
$13,708.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,708.67
|
|
|
Frenoplasty (surgical revision of frenum, eg, with Z-plasty)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 41520
|
| Min. Negotiated Rate |
$365.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$365.90
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Frenulotomy of penis
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54164
|
| Min. Negotiated Rate |
$242.19 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$242.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,544.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15240
|
| Min. Negotiated Rate |
$105.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
