|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
|
IP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$33.44 |
| Rate for Payer: Blue Shield of California Commercial |
$28.01
|
| Rate for Payer: Blue Shield of California EPN |
$20.14
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.74
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.44
|
| Rate for Payer: Multiplan Commercial |
$31.47
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.85
|
| Rate for Payer: United Healthcare All Other HMO |
$14.51
|
| Rate for Payer: United Healthcare HMO Rider |
$14.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.98
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 11044
|
| Min. Negotiated Rate |
$225.00 |
| 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 |
$3,038.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Media |
$2,025.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,322.13
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,322.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,281.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,281.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$384.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 11012
|
| Min. Negotiated Rate |
$731.42 |
| 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 |
$5,325.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Media |
$3,550.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,792.85
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,550.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,822.43
|
| Rate for Payer: Heritage Provider Network Transplant |
$5,822.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,751.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$5,751.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$731.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,550.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,757.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
|
OP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$466.55 |
| Max. Negotiated Rate |
$1,652.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,275.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,069.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,069.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,158.21
|
| Rate for Payer: Blue Distinction Transplant |
$1,166.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1,432.69
|
| Rate for Payer: Blue Shield of California EPN |
$1,135.27
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Dignity Health Media |
$1,652.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,652.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,457.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$740.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.55
|
| Rate for Payer: Multiplan Commercial |
$1,555.16
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,166.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,166.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$971.98
|
| Rate for Payer: United Healthcare All Other HMO |
$971.98
|
| Rate for Payer: United Healthcare HMO Rider |
$971.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$971.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1,652.36
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
|
IP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$466.55 |
| Max. Negotiated Rate |
$1,652.36 |
| Rate for Payer: Blue Shield of California Commercial |
$1,384.09
|
| Rate for Payer: Blue Shield of California EPN |
$995.30
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$740.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$466.55
|
| Rate for Payer: Multiplan Commercial |
$1,555.16
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$396.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$130.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.33
|
| Rate for Payer: Blue Distinction Transplant |
$142.56
|
| Rate for Payer: Blue Distinction Transplant |
$72.00
|
| Rate for Payer: Blue Distinction Transplant |
$432.00
|
| Rate for Payer: Blue Distinction Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$176.88
|
| Rate for Payer: Blue Shield of California Commercial |
$175.11
|
| Rate for Payer: Blue Shield of California Commercial |
$88.44
|
| Rate for Payer: Blue Shield of California Commercial |
$530.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Media |
$612.00
|
| Rate for Payer: Dignity Health Media |
$102.00
|
| Rate for Payer: Dignity Health Media |
$201.96
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$612.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$90.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$540.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$178.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.80
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$190.08
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$432.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$432.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$118.80
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO |
$118.80
|
| Rate for Payer: United Healthcare HMO Rider |
$360.00
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$118.80
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$360.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$118.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
IP
|
$237.60
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.02 |
| Max. Negotiated Rate |
$201.96 |
| Rate for Payer: Blue Shield of California Commercial |
$169.17
|
| Rate for Payer: Blue Shield of California Commercial |
$512.64
|
| Rate for Payer: Blue Shield of California Commercial |
$85.44
|
| Rate for Payer: Blue Shield of California Commercial |
$170.88
|
| Rate for Payer: Blue Shield of California EPN |
$368.64
|
| Rate for Payer: Blue Shield of California EPN |
$121.65
|
| Rate for Payer: Blue Shield of California EPN |
$122.88
|
| Rate for Payer: Blue Shield of California EPN |
$61.44
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$172.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.80
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$190.08
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$576.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$89.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.31
|
| Rate for Payer: United Healthcare All Other HMO |
$88.51
|
| Rate for Payer: United Healthcare All Other HMO |
$265.54
|
| Rate for Payer: United Healthcare All Other HMO |
$87.63
|
| Rate for Payer: United Healthcare All Other HMO |
$44.26
|
| Rate for Payer: United Healthcare HMO Rider |
$86.59
|
| Rate for Payer: United Healthcare HMO Rider |
$85.73
|
| Rate for Payer: United Healthcare HMO Rider |
$259.78
|
| Rate for Payer: United Healthcare HMO Rider |
$43.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$79.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$237.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$78.41
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Blue Shield of California Commercial |
$83.27
|
| Rate for Payer: Blue Shield of California EPN |
$59.88
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.68
|
| Rate for Payer: Blue Distinction Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$86.19
|
| Rate for Payer: Blue Shield of California EPN |
$68.30
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Media |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$87.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.68
|
| Rate for Payer: Blue Distinction Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$86.19
|
| Rate for Payer: Blue Shield of California EPN |
$68.30
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Media |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$87.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Blue Shield of California Commercial |
$83.27
|
| Rate for Payer: Blue Shield of California EPN |
$59.88
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.56
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$51.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$39.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.80
|
| Rate for Payer: Blue Distinction Transplant |
$36.05
|
| Rate for Payer: Blue Shield of California Commercial |
$44.28
|
| Rate for Payer: Blue Shield of California EPN |
$35.09
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.07
|
| Rate for Payer: Dignity Health Media |
$51.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$45.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.42
|
| Rate for Payer: Multiplan Commercial |
$48.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.04
|
| Rate for Payer: United Healthcare All Other HMO |
$30.04
|
| Rate for Payer: United Healthcare HMO Rider |
$30.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.07
|
| Rate for Payer: Vantage Medical Group Senior |
$51.07
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$51.07 |
| Rate for Payer: Blue Shield of California Commercial |
$42.78
|
| Rate for Payer: Blue Shield of California EPN |
$30.76
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.42
|
| Rate for Payer: Multiplan Commercial |
$48.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
IP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.13 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Blue Shield of California Commercial |
$166.53
|
| Rate for Payer: Blue Shield of California EPN |
$119.75
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.13
|
| Rate for Payer: Multiplan Commercial |
$187.11
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
OP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.13 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$153.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$128.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$128.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$139.35
|
| Rate for Payer: Blue Distinction Transplant |
$140.33
|
| Rate for Payer: Blue Shield of California Commercial |
$172.38
|
| Rate for Payer: Blue Shield of California EPN |
$136.59
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$198.81
|
| Rate for Payer: Dignity Health Media |
$198.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$198.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$175.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.13
|
| Rate for Payer: Multiplan Commercial |
$187.11
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$140.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$140.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.94
|
| Rate for Payer: United Healthcare All Other HMO |
$116.94
|
| Rate for Payer: United Healthcare HMO Rider |
$116.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$198.81
|
| Rate for Payer: Vantage Medical Group Senior |
$198.81
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
IP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Blue Shield of California Commercial |
$35.20
|
| Rate for Payer: Blue Shield of California EPN |
$25.31
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.67
|
| Rate for Payer: United Healthcare All Other HMO |
$18.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.32
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
|
OP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: Blue Distinction Transplant |
$29.66
|
| Rate for Payer: Blue Shield of California Commercial |
$36.44
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: Dignity Health Media |
$42.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$37.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.87
|
| Rate for Payer: Multiplan Commercial |
$39.55
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.72
|
| Rate for Payer: United Healthcare All Other HMO |
$24.72
|
| Rate for Payer: United Healthcare HMO Rider |
$24.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: Blue Distinction Transplant |
$9.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Media |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.77
|
| Rate for Payer: United Healthcare HMO Rider |
$7.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$7.96
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.87
|
| Rate for Payer: United Healthcare All Other HMO |
$5.73
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.13
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$13.21 |
| Rate for Payer: Blue Shield of California Commercial |
$11.06
|
| Rate for Payer: Blue Shield of California EPN |
$7.96
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.87
|
| Rate for Payer: United Healthcare All Other HMO |
$5.73
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.13
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$54.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.87
|
| Rate for Payer: Blue Distinction Transplant |
$9.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.45
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Media |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.43
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.77
|
| Rate for Payer: United Healthcare HMO Rider |
$7.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
|
IP
|
$61,161.32
|
|
|
Service Code
|
APR-DRG 1792
|
| Min. Negotiated Rate |
$46,917.17 |
| Max. Negotiated Rate |
$61,161.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46,917.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61,161.32
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
|
IP
|
$75,065.24
|
|
|
Service Code
|
APR-DRG 1793
|
| Min. Negotiated Rate |
$57,582.94 |
| Max. Negotiated Rate |
$75,065.24 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$57,582.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$75,065.24
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
|
IP
|
$53,968.17
|
|
|
Service Code
|
APR-DRG 1791
|
| Min. Negotiated Rate |
$41,399.27 |
| Max. Negotiated Rate |
$53,968.17 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41,399.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$53,968.17
|
|
|
DEFIBRILLATOR IMPLANTS
|
Facility
|
IP
|
$102,947.59
|
|
|
Service Code
|
APR-DRG 1794
|
| Min. Negotiated Rate |
$78,971.64 |
| Max. Negotiated Rate |
$102,947.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$78,971.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102,947.59
|
|
