|
Insertion or replacement of spinal neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver
|
Facility
|
OP
|
$73,715.61
|
|
|
Service Code
|
CPT 63685
|
| Min. Negotiated Rate |
$117.90 |
| Max. Negotiated Rate |
$73,715.61 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58,196.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42,677.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$38,797.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58,196.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$42,677.46
|
| Rate for Payer: Dignity Health Senior |
$38,797.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$38,797.69
|
| Rate for Payer: Humana Medicare |
$38,797.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$117.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38,797.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$73,715.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$45,781.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48,885.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48,885.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$42,677.46
|
| Rate for Payer: TriValley Medical Group Senior |
$38,797.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58,196.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42,677.46
|
| Rate for Payer: Vantage Medical Group Senior |
$38,797.69
|
|
|
INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES
|
Facility
|
IP
|
$17,429.58
|
|
|
Service Code
|
APR-DRG 1762
|
| Min. Negotiated Rate |
$17,429.58 |
| Max. Negotiated Rate |
$17,429.58 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,429.58
|
|
|
INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES
|
Facility
|
IP
|
$44,722.56
|
|
|
Service Code
|
APR-DRG 1764
|
| Min. Negotiated Rate |
$44,722.56 |
| Max. Negotiated Rate |
$44,722.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44,722.56
|
|
|
INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES
|
Facility
|
IP
|
$14,691.63
|
|
|
Service Code
|
APR-DRG 1761
|
| Min. Negotiated Rate |
$14,691.63 |
| Max. Negotiated Rate |
$14,691.63 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,691.63
|
|
|
INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES
|
Facility
|
IP
|
$27,001.48
|
|
|
Service Code
|
APR-DRG 1763
|
| Min. Negotiated Rate |
$27,001.48 |
| Max. Negotiated Rate |
$27,001.48 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,001.48
|
|
|
Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 50391
|
| Min. Negotiated Rate |
$185.94 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$308.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$463.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$339.67
|
| Rate for Payer: Dignity Health Senior |
$308.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$308.79
|
| Rate for Payer: Humana Medicare |
$308.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$185.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$308.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$586.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$364.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$389.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$389.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$339.67
|
| Rate for Payer: TriValley Medical Group Senior |
$308.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$463.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$339.67
|
| Rate for Payer: Vantage Medical Group Senior |
$308.79
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
IP
|
$40.67
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
NDG223708
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$30.50 |
| Rate for Payer: Adventist Health Commercial |
$8.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.94
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.53
|
| Rate for Payer: Heritage Provider Network Senior |
$27.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$30.50
|
|
|
INSULIN DEGLUDEC (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION [223708]
|
Facility
|
OP
|
$40.67
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
NDG223708
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$34.57 |
| Rate for Payer: Adventist Health Commercial |
$8.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$34.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$25.26
|
| Rate for Payer: Blue Shield of California EPN |
$23.87
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.57
|
| Rate for Payer: Dignity Health Senior |
$34.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.17
|
| Rate for Payer: Heritage Provider Network Senior |
$25.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.17
|
| Rate for Payer: Multiplan Commercial |
$30.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.27
|
| Rate for Payer: TriValley Medical Group Senior |
$16.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.57
|
| Rate for Payer: Vantage Medical Group Senior |
$34.57
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
OP
|
$35.05
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
1721115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$29.79 |
| Rate for Payer: Adventist Health Commercial |
$7.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$21.77
|
| Rate for Payer: Blue Shield of California EPN |
$20.57
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.79
|
| Rate for Payer: Dignity Health Senior |
$29.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.70
|
| Rate for Payer: Heritage Provider Network Senior |
$21.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.76
|
| Rate for Payer: Multiplan Commercial |
$26.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.02
|
| Rate for Payer: TriValley Medical Group Senior |
$14.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.79
|
| Rate for Payer: Vantage Medical Group Senior |
$29.79
|
|
|
INSULIN GLARGINE VIAL (LANTUS) 100 UNIT/ML SUBCUTANEOUS [28282]
|
Facility
|
IP
|
$35.05
|
|
|
Service Code
|
CPT J1815
|
| Hospital Charge Code |
1721115
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Adventist Health Commercial |
$7.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.73
|
| Rate for Payer: Heritage Provider Network Senior |
$23.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.76
|
| Rate for Payer: Multiplan Commercial |
$26.29
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$34.07
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.41
|
| Rate for Payer: Cash Price |
$15.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.07
|
| Rate for Payer: Heritage Provider Network Senior |
$23.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.52
|
| Rate for Payer: Multiplan Commercial |
$25.55
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$34.07
|
|
|
Service Code
|
NDC 0088-2500-33
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$28.96 |
| Rate for Payer: Adventist Health Commercial |
$6.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.55
|
| Rate for Payer: Blue Shield of California Commercial |
$21.16
|
| Rate for Payer: Blue Shield of California EPN |
$20.00
|
| Rate for Payer: Cash Price |
$15.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.96
|
| Rate for Payer: Dignity Health Senior |
$28.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.09
|
| Rate for Payer: Heritage Provider Network Senior |
$21.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.52
|
| Rate for Payer: Multiplan Commercial |
$25.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.63
|
| Rate for Payer: TriValley Medical Group Senior |
$13.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.96
|
| Rate for Payer: Vantage Medical Group Senior |
$28.96
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
OP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$22.77 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.09
|
| Rate for Payer: Blue Shield of California Commercial |
$16.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.73
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.77
|
| Rate for Payer: Dignity Health Senior |
$22.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.58
|
| Rate for Payer: Heritage Provider Network Senior |
$16.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.72
|
| Rate for Payer: TriValley Medical Group Senior |
$10.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.77
|
| Rate for Payer: Vantage Medical Group Senior |
$22.77
|
|
|
INSULIN GLULISINE (APIDRA) 100 UNIT/ML BOLUS FROM PUMP [4081881]
|
Facility
|
IP
|
$26.79
|
|
|
Service Code
|
NDC 0088-2500-34
|
| Hospital Charge Code |
1721127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Adventist Health Commercial |
$5.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.40
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.14
|
| Rate for Payer: Heritage Provider Network Senior |
$18.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$20.09
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
NDG225937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION [225937]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 0338-0126-12
|
| Hospital Charge Code |
NDG225937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
OP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-01
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$97.61 |
| Rate for Payer: Adventist Health Commercial |
$22.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.13
|
| Rate for Payer: Blue Shield of California Commercial |
$71.32
|
| Rate for Payer: Blue Shield of California EPN |
$67.41
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.61
|
| Rate for Payer: Dignity Health Senior |
$97.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.09
|
| Rate for Payer: Heritage Provider Network Senior |
$71.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.71
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.94
|
| Rate for Payer: TriValley Medical Group Senior |
$45.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.61
|
| Rate for Payer: Vantage Medical Group Senior |
$97.61
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
OP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-27
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$97.61 |
| Rate for Payer: Adventist Health Commercial |
$22.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.13
|
| Rate for Payer: Blue Shield of California Commercial |
$71.32
|
| Rate for Payer: Blue Shield of California EPN |
$67.41
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.61
|
| Rate for Payer: Dignity Health Senior |
$97.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.09
|
| Rate for Payer: Heritage Provider Network Senior |
$71.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.71
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.94
|
| Rate for Payer: TriValley Medical Group Senior |
$45.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.61
|
| Rate for Payer: Vantage Medical Group Senior |
$97.61
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
IP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-27
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Adventist Health Commercial |
$22.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.90
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.75
|
| Rate for Payer: Heritage Provider Network Senior |
$77.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.71
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
|
|
INSULIN REGULAR HUMAN U-500 "CONCENTRATE" 500 UNIT/ML(3 ML) SUBCUT PEN [213661]
|
Facility
|
IP
|
$114.84
|
|
|
Service Code
|
NDC 0002-8824-01
|
| Hospital Charge Code |
NDG213661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$86.13 |
| Rate for Payer: Adventist Health Commercial |
$22.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$78.90
|
| Rate for Payer: Cash Price |
$51.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.75
|
| Rate for Payer: Heritage Provider Network Senior |
$77.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.71
|
| Rate for Payer: Multiplan Commercial |
$86.13
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$12,620.25
|
|
|
Service Code
|
APR-DRG 8174
|
| Min. Negotiated Rate |
$12,620.25 |
| Max. Negotiated Rate |
$12,620.25 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,620.25
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$3,393.59
|
|
|
Service Code
|
APR-DRG 8171
|
| Min. Negotiated Rate |
$3,393.59 |
| Max. Negotiated Rate |
$3,393.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,393.59
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$4,278.05
|
|
|
Service Code
|
APR-DRG 8172
|
| Min. Negotiated Rate |
$4,278.05 |
| Max. Negotiated Rate |
$4,278.05 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,278.05
|
|
|
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE
|
Facility
|
IP
|
$6,951.33
|
|
|
Service Code
|
APR-DRG 8173
|
| Min. Negotiated Rate |
$6,951.33 |
| Max. Negotiated Rate |
$6,951.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,951.33
|
|
|
Interdental wiring, for condition other than fracture
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21497
|
| Min. Negotiated Rate |
$83.05 |
| 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 |
$2,858.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: Dignity Health Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,905.44
|
| Rate for Payer: Humana Medicare |
$1,905.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,620.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,248.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,400.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,095.98
|
| Rate for Payer: TriValley Medical Group Senior |
$1,905.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
