|
DW1YBBZ
|
Facility
|
IP
|
$9,120.00
|
|
|
Service Code
|
ICD DW1YBBZ
|
| Hospital Charge Code |
5588
|
| Min. Negotiated Rate |
$9,120.00 |
| Max. Negotiated Rate |
$9,120.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,120.00
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$12,242.76
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$9,136.39 |
| Max. Negotiated Rate |
$12,242.76 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,136.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,136.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,506.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,242.76
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC
|
Facility
|
IP
|
$20,226.05
|
|
|
Service Code
|
MSDRG 147
|
| Min. Negotiated Rate |
$15,094.07 |
| Max. Negotiated Rate |
$20,226.05 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,094.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,094.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17,358.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$20,226.05
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$33,215.25
|
|
|
Service Code
|
MSDRG 146
|
| Min. Negotiated Rate |
$24,787.50 |
| Max. Negotiated Rate |
$33,215.25 |
| Rate for Payer: EPIC Health Plan Medicare |
$24,787.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,787.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,505.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33,215.25
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$12,941.43
|
|
|
Service Code
|
MSDRG 148
|
| Min. Negotiated Rate |
$9,657.78 |
| Max. Negotiated Rate |
$12,941.43 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,657.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,657.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,106.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,941.43
|
|
|
ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$326,624.42
|
|
|
Service Code
|
MSDRG 003
|
| Min. Negotiated Rate |
$243,749.57 |
| Max. Negotiated Rate |
$326,624.42 |
| Rate for Payer: EPIC Health Plan Medicare |
$243,749.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$243,749.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$280,312.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$326,624.42
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 5167213031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.29
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 5167213031
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
IP
|
$260.92
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$195.69 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$168.03
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$140.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.81
|
| Rate for Payer: Heritage Provider Network Senior |
$120.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$47.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$94.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$86.39
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]
|
Facility
|
OP
|
$260.92
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$195.69 |
| Rate for Payer: Adventist Health Commercial |
$52.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$161.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$48.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$105.43
|
| Rate for Payer: Blue Shield of California Commercial |
$159.16
|
| Rate for Payer: Blue Shield of California EPN |
$127.33
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cash Price |
$117.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.81
|
| Rate for Payer: Heritage Provider Network Senior |
$120.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$124.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$47.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$59.23
|
| Rate for Payer: Multiplan Commercial |
$195.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$104.37
|
| Rate for Payer: TriValley Medical Group Senior |
$104.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$94.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$86.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.62
|
| Rate for Payer: Vantage Medical Group Senior |
$48.62
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Blue Shield of California Commercial |
$18.30
|
| Rate for Payer: Blue Shield of California EPN |
$14.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.00
|
| Rate for Payer: TriValley Medical Group Senior |
$12.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
EDETATE DISODIUM 3 % EYE DROPS [222529]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.32
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.89
|
| Rate for Payer: Heritage Provider Network Senior |
$13.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.93
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 3172250430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.17
|
| Rate for Payer: Heritage Provider Network Senior |
$2.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
|
|
EFAVIRENZ 600 MG TABLET [32298]
|
Facility
|
OP
|
$3.20
|
|
|
Service Code
|
NDC 3172250430
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.98
|
| Rate for Payer: Heritage Provider Network Senior |
$1.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.72
|
| Rate for Payer: Vantage Medical Group Senior |
$2.72
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
|
IP
|
$9,000.00
|
|
|
Service Code
|
HCPCS J1449
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,629.00 |
| Max. Negotiated Rate |
$6,750.00 |
| Rate for Payer: Adventist Health Commercial |
$1,800.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,796.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,140.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,860.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,167.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,167.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,629.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,250.00
|
| Rate for Payer: Multiplan Commercial |
$6,750.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,251.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,979.90
|
|
|
EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]
|
Facility
|
OP
|
$9,000.00
|
|
|
Service Code
|
HCPCS J1449
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.77 |
| Max. Negotiated Rate |
$6,750.00 |
| Rate for Payer: Adventist Health Commercial |
$1,800.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,562.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.65
|
| Rate for Payer: Blue Shield of California Commercial |
$34.77
|
| Rate for Payer: Blue Shield of California EPN |
$34.77
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cash Price |
$4,050.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,140.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,760.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$38.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,167.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,167.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,293.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,629.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$44.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,250.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$6,750.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,600.00
|
| Rate for Payer: TriValley Medical Group Senior |
$3,600.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,251.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,979.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.42
|
| Rate for Payer: Vantage Medical Group Senior |
$42.42
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
|
|
ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
ELECTROLYTE-S IV BOLUS [192101]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.00
|
| Rate for Payer: Heritage Provider Network Senior |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.00
|
|
|
ELETRIPTAN 20 MG TABLET [34683]
|
Facility
|
OP
|
$96.92
|
|
|
Service Code
|
NDC 0049233045
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$82.38 |
| Rate for Payer: Adventist Health Commercial |
$19.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$59.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$82.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.48
|
| Rate for Payer: Blue Shield of California Commercial |
$59.12
|
| Rate for Payer: Blue Shield of California EPN |
$47.30
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$63.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$82.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$82.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$82.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.99
|
| Rate for Payer: Heritage Provider Network Senior |
$59.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$46.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.84
|
| Rate for Payer: Multiplan Commercial |
$72.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.77
|
| Rate for Payer: TriValley Medical Group Senior |
$38.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$48.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$82.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$82.38
|
| Rate for Payer: Vantage Medical Group Senior |
$82.38
|
|
