|
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
|
Facility
|
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 14301
|
| Min. Negotiated Rate |
$337.42 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Media |
$4,482.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,351.30
|
| Rate for Payer: Heritage Provider Network Transplant |
$7,351.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,261.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$7,261.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$337.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 14040
|
| Min. Negotiated Rate |
$128.04 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| 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 |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,736.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 14000
|
| Min. Negotiated Rate |
$84.89 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| 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 |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,736.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,691.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| 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
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$6,771.07
|
|
|
Service Code
|
APR-DRG 7552
|
| Min. Negotiated Rate |
$5,194.12 |
| Max. Negotiated Rate |
$6,771.07 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,194.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,771.07
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$18,298.56
|
|
|
Service Code
|
APR-DRG 7554
|
| Min. Negotiated Rate |
$14,036.92 |
| Max. Negotiated Rate |
$18,298.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14,036.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,298.56
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$10,614.16
|
|
|
Service Code
|
APR-DRG 7553
|
| Min. Negotiated Rate |
$8,142.18 |
| Max. Negotiated Rate |
$10,614.16 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,142.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,614.16
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
|
IP
|
$4,618.08
|
|
|
Service Code
|
APR-DRG 7551
|
| Min. Negotiated Rate |
$3,542.56 |
| Max. Negotiated Rate |
$4,618.08 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,542.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,618.08
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
|
IP
|
$4,490.48
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,077.72 |
| Max. Negotiated Rate |
$3,816.91 |
| Rate for Payer: Blue Shield of California Commercial |
$3,197.22
|
| Rate for Payer: Blue Shield of California EPN |
$2,299.13
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cigna of CA HMO |
$3,143.34
|
| Rate for Payer: Cigna of CA PPO |
$3,143.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,796.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,796.19
|
| Rate for Payer: Galaxy Health WC |
$3,816.91
|
| Rate for Payer: Global Benefits Group Commercial |
$2,694.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,995.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,710.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,077.72
|
| Rate for Payer: Multiplan Commercial |
$3,592.38
|
| Rate for Payer: Networks By Design Commercial |
$2,245.24
|
| Rate for Payer: Prime Health Services Commercial |
$3,816.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,695.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1,656.09
|
| Rate for Payer: United Healthcare HMO Rider |
$1,620.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,481.86
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
|
OP
|
$4,490.48
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.85 |
| Max. Negotiated Rate |
$3,816.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$241.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.13
|
| Rate for Payer: Blue Distinction Transplant |
$2,694.29
|
| Rate for Payer: Blue Shield of California Commercial |
$3,309.48
|
| Rate for Payer: Blue Shield of California EPN |
$37.85
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cigna of CA HMO |
$3,143.34
|
| Rate for Payer: Cigna of CA PPO |
$3,143.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.55
|
| Rate for Payer: Dignity Health Media |
$38.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$38.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.37
|
| Rate for Payer: Galaxy Health WC |
$3,816.91
|
| Rate for Payer: Global Benefits Group Commercial |
$2,694.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3,367.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$62.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$62.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$62.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,995.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,077.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.41
|
| Rate for Payer: Multiplan Commercial |
$3,592.38
|
| Rate for Payer: Networks By Design Commercial |
$2,245.24
|
| Rate for Payer: Prime Health Services Commercial |
$3,816.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,694.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,694.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,245.24
|
| Rate for Payer: United Healthcare All Other HMO |
$2,245.24
|
| Rate for Payer: United Healthcare HMO Rider |
$2,245.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,245.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Vantage Medical Group Senior |
$38.37
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
|
IP
|
$7,184.76
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,724.34 |
| Max. Negotiated Rate |
$6,107.05 |
| Rate for Payer: Blue Shield of California Commercial |
$5,115.55
|
| Rate for Payer: Blue Shield of California EPN |
$3,678.60
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cigna of CA HMO |
$5,029.33
|
| Rate for Payer: Cigna of CA PPO |
$5,029.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,873.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,873.90
|
| Rate for Payer: Galaxy Health WC |
$6,107.05
|
| Rate for Payer: Global Benefits Group Commercial |
$4,310.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,792.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,737.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,724.34
|
| Rate for Payer: Multiplan Commercial |
$5,747.81
|
| Rate for Payer: Networks By Design Commercial |
$3,592.38
|
| Rate for Payer: Prime Health Services Commercial |
$6,107.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,712.97
|
| Rate for Payer: United Healthcare All Other HMO |
$2,649.74
|
| Rate for Payer: United Healthcare HMO Rider |
$2,592.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,370.97
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
|
OP
|
$7,184.76
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.85 |
| Max. Negotiated Rate |
$6,107.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$241.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.13
|
| Rate for Payer: Blue Distinction Transplant |
$4,310.86
|
| Rate for Payer: Blue Shield of California Commercial |
$5,295.17
|
| Rate for Payer: Blue Shield of California EPN |
$37.85
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cigna of CA HMO |
$5,029.33
|
| Rate for Payer: Cigna of CA PPO |
$5,029.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.55
|
| Rate for Payer: Dignity Health Media |
$38.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.80
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$38.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.37
|
| Rate for Payer: Galaxy Health WC |
$6,107.05
|
| Rate for Payer: Global Benefits Group Commercial |
$4,310.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5,388.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$62.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$62.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$62.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,792.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$81.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,724.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.41
|
| Rate for Payer: Multiplan Commercial |
$5,747.81
|
| Rate for Payer: Networks By Design Commercial |
$3,592.38
|
| Rate for Payer: Prime Health Services Commercial |
$6,107.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,310.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,310.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,592.38
|
| Rate for Payer: United Healthcare All Other HMO |
$3,592.38
|
| Rate for Payer: United Healthcare HMO Rider |
$3,592.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,592.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Vantage Medical Group Senior |
$38.37
|
|
|
ADRENAL PROCEDURES
|
Facility
|
IP
|
$20,510.06
|
|
|
Service Code
|
APR-DRG 4011
|
| Min. Negotiated Rate |
$15,733.38 |
| Max. Negotiated Rate |
$20,510.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,733.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,510.06
|
|
|
ADRENAL PROCEDURES
|
Facility
|
IP
|
$76,150.59
|
|
|
Service Code
|
APR-DRG 4014
|
| Min. Negotiated Rate |
$58,415.52 |
| Max. Negotiated Rate |
$76,150.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58,415.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76,150.59
|
|
|
ADRENAL PROCEDURES
|
Facility
|
IP
|
$45,354.46
|
|
|
Service Code
|
APR-DRG 4013
|
| Min. Negotiated Rate |
$34,791.65 |
| Max. Negotiated Rate |
$45,354.46 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34,791.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45,354.46
|
|
|
ADRENAL PROCEDURES
|
Facility
|
IP
|
$36,141.34
|
|
|
Service Code
|
APR-DRG 4012
|
| Min. Negotiated Rate |
$27,724.22 |
| Max. Negotiated Rate |
$36,141.34 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,724.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36,141.34
|
|
|
AFLIBERCEPT 2 MG/0.05 ML INTRAVITREAL SOLUTION FOR INJECTION [152966]
|
Facility
|
OP
|
$44,400.00
|
|
|
Service Code
|
CPT J0178
|
| Hospital Charge Code |
NDG152966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.28 |
| Max. Negotiated Rate |
$37,740.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5,423.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,077.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$948.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$948.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,971.57
|
| Rate for Payer: Blue Distinction Transplant |
$26,640.00
|
| Rate for Payer: Blue Shield of California Commercial |
$32,722.80
|
| Rate for Payer: Blue Shield of California EPN |
$1,110.00
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Cigna of CA HMO |
$31,080.00
|
| Rate for Payer: Cigna of CA PPO |
$31,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,293.42
|
| Rate for Payer: Dignity Health Media |
$862.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$948.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,164.08
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$862.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$862.28
|
| Rate for Payer: Galaxy Health WC |
$37,740.00
|
| Rate for Payer: Global Benefits Group Commercial |
$26,640.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$33,300.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,414.14
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,414.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,396.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$1,396.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$862.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$29,614.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,646.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$862.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,656.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,086.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,155.46
|
| Rate for Payer: Multiplan Commercial |
$35,520.00
|
| Rate for Payer: Networks By Design Commercial |
$22,200.00
|
| Rate for Payer: Prime Health Services Commercial |
$37,740.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$26,640.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$26,640.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$22,200.00
|
| Rate for Payer: United Healthcare All Other HMO |
$22,200.00
|
| Rate for Payer: United Healthcare HMO Rider |
$22,200.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22,200.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,293.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$948.51
|
| Rate for Payer: Vantage Medical Group Senior |
$862.28
|
|
|
AFLIBERCEPT 2 MG/0.05 ML INTRAVITREAL SOLUTION FOR INJECTION [152966]
|
Facility
|
IP
|
$44,400.00
|
|
|
Service Code
|
CPT J0178
|
| Hospital Charge Code |
NDG152966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,656.00 |
| Max. Negotiated Rate |
$37,740.00 |
| Rate for Payer: Blue Shield of California Commercial |
$31,612.80
|
| Rate for Payer: Blue Shield of California EPN |
$22,732.80
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Cigna of CA HMO |
$31,080.00
|
| Rate for Payer: Cigna of CA PPO |
$31,080.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$17,760.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$17,760.00
|
| Rate for Payer: Galaxy Health WC |
$37,740.00
|
| Rate for Payer: Global Benefits Group Commercial |
$26,640.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$29,614.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,916.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10,656.00
|
| Rate for Payer: Multiplan Commercial |
$35,520.00
|
| Rate for Payer: Networks By Design Commercial |
$22,200.00
|
| Rate for Payer: Prime Health Services Commercial |
$37,740.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,765.44
|
| Rate for Payer: United Healthcare All Other HMO |
$16,374.72
|
| Rate for Payer: United Healthcare HMO Rider |
$16,019.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,652.00
|
|
|
AGALSIDASE BETA 35 MG INTRAVENOUS SOLUTION [35775]
|
Facility
|
OP
|
$8,685.12
|
|
|
Service Code
|
CPT J0180
|
| Hospital Charge Code |
1755755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.32 |
| Max. Negotiated Rate |
$7,382.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,373.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$272.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$240.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$240.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$253.65
|
| Rate for Payer: Blue Distinction Transplant |
$5,211.07
|
| Rate for Payer: Blue Shield of California Commercial |
$6,400.93
|
| Rate for Payer: Blue Shield of California EPN |
$214.32
|
| Rate for Payer: Cash Price |
$3,908.30
|
| Rate for Payer: Cash Price |
$3,908.30
|
| Rate for Payer: Cigna of CA HMO |
$6,079.58
|
| Rate for Payer: Cigna of CA PPO |
$6,079.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$327.51
|
| Rate for Payer: Dignity Health Media |
$218.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$240.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$294.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$218.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$218.34
|
| Rate for Payer: Galaxy Health WC |
$7,382.35
|
| Rate for Payer: Global Benefits Group Commercial |
$5,211.07
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6,513.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$358.08
|
| Rate for Payer: Heritage Provider Network Transplant |
$358.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$353.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$353.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$218.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,792.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$423.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$218.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,084.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$275.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$292.58
|
| Rate for Payer: Multiplan Commercial |
$6,948.10
|
| Rate for Payer: Networks By Design Commercial |
$4,342.56
|
| Rate for Payer: Prime Health Services Commercial |
$7,382.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,211.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,211.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,342.56
|
| Rate for Payer: United Healthcare All Other HMO |
$4,342.56
|
| Rate for Payer: United Healthcare HMO Rider |
$4,342.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,342.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$327.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$240.18
|
| Rate for Payer: Vantage Medical Group Senior |
$218.34
|
|
|
AGALSIDASE BETA 35 MG INTRAVENOUS SOLUTION [35775]
|
Facility
|
IP
|
$8,685.12
|
|
|
Service Code
|
CPT J0180
|
| Hospital Charge Code |
1755755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,084.43 |
| Max. Negotiated Rate |
$7,382.35 |
| Rate for Payer: Blue Shield of California Commercial |
$6,183.81
|
| Rate for Payer: Blue Shield of California EPN |
$4,446.78
|
| Rate for Payer: Cash Price |
$3,908.30
|
| Rate for Payer: Cigna of CA HMO |
$6,079.58
|
| Rate for Payer: Cigna of CA PPO |
$6,079.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,474.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,474.05
|
| Rate for Payer: Galaxy Health WC |
$7,382.35
|
| Rate for Payer: Global Benefits Group Commercial |
$5,211.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,792.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,309.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,084.43
|
| Rate for Payer: Multiplan Commercial |
$6,948.10
|
| Rate for Payer: Networks By Design Commercial |
$4,342.56
|
| Rate for Payer: Prime Health Services Commercial |
$7,382.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,279.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3,203.07
|
| Rate for Payer: United Healthcare HMO Rider |
$3,133.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,866.09
|
|
|
AGALSIDASE BETA 5 MG INTRAVENOUS SOLUTION [38494]
|
Facility
|
OP
|
$1,240.52
|
|
|
Service Code
|
CPT J0180
|
| Hospital Charge Code |
1755754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.32 |
| Max. Negotiated Rate |
$1,373.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,373.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$272.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$240.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$240.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$253.65
|
| Rate for Payer: Blue Distinction Transplant |
$744.31
|
| Rate for Payer: Blue Shield of California Commercial |
$914.26
|
| Rate for Payer: Blue Shield of California EPN |
$214.32
|
| Rate for Payer: Cash Price |
$558.23
|
| Rate for Payer: Cash Price |
$558.23
|
| Rate for Payer: Cigna of CA HMO |
$868.36
|
| Rate for Payer: Cigna of CA PPO |
$868.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$327.51
|
| Rate for Payer: Dignity Health Media |
$218.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$240.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$294.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$218.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$218.34
|
| Rate for Payer: Galaxy Health WC |
$1,054.44
|
| Rate for Payer: Global Benefits Group Commercial |
$744.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$930.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$358.08
|
| Rate for Payer: Heritage Provider Network Transplant |
$358.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$353.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$353.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$218.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$827.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$423.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$218.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$275.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$292.58
|
| Rate for Payer: Multiplan Commercial |
$992.42
|
| Rate for Payer: Networks By Design Commercial |
$620.26
|
| Rate for Payer: Prime Health Services Commercial |
$1,054.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$744.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$744.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$620.26
|
| Rate for Payer: United Healthcare All Other HMO |
$620.26
|
| Rate for Payer: United Healthcare HMO Rider |
$620.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$620.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$327.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$240.18
|
| Rate for Payer: Vantage Medical Group Senior |
$218.34
|
|
|
AGALSIDASE BETA 5 MG INTRAVENOUS SOLUTION [38494]
|
Facility
|
IP
|
$1,240.52
|
|
|
Service Code
|
CPT J0180
|
| Hospital Charge Code |
1755754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.72 |
| Max. Negotiated Rate |
$1,054.44 |
| Rate for Payer: Blue Shield of California Commercial |
$883.25
|
| Rate for Payer: Blue Shield of California EPN |
$635.15
|
| Rate for Payer: Cash Price |
$558.23
|
| Rate for Payer: Cigna of CA HMO |
$868.36
|
| Rate for Payer: Cigna of CA PPO |
$868.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$496.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$496.21
|
| Rate for Payer: Galaxy Health WC |
$1,054.44
|
| Rate for Payer: Global Benefits Group Commercial |
$744.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$827.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$472.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$297.72
|
| Rate for Payer: Multiplan Commercial |
$992.42
|
| Rate for Payer: Networks By Design Commercial |
$620.26
|
| Rate for Payer: Prime Health Services Commercial |
$1,054.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$468.42
|
| Rate for Payer: United Healthcare All Other HMO |
$457.50
|
| Rate for Payer: United Healthcare HMO Rider |
$447.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$409.37
|
|
|
AGAR (BULK) 100 % POWDER [40822641]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 9999-9226-41
|
| Hospital Charge Code |
1713148
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
AGAR (BULK) 100 % POWDER [40822641]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 9999-9226-41
|
| Hospital Charge Code |
1713148
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
NDC 31722-935-02
|
| Hospital Charge Code |
1712227
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Blue Shield of California Commercial |
$25.63
|
| Rate for Payer: Blue Shield of California EPN |
$18.43
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$25.20
|
| Rate for Payer: Cigna of CA PPO |
$25.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
|
|
ALBENDAZOLE 200 MG TABLET [8979]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
NDC 31722-935-02
|
| Hospital Charge Code |
1712227
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.45
|
| Rate for Payer: Blue Distinction Transplant |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$26.53
|
| Rate for Payer: Blue Shield of California EPN |
$21.02
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$25.20
|
| Rate for Payer: Cigna of CA PPO |
$25.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Media |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$27.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$24.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.00
|
| Rate for Payer: United Healthcare All Other HMO |
$18.00
|
| Rate for Payer: United Healthcare HMO Rider |
$18.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
