|
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
|
Facility
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 14060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 14041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
|
Facility
OP
|
$7,027.00
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$7,027.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 14021
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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, scalp, arms and/or legs; defect 10 sq cm or less
|
Facility
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 14020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$8,114.00
|
|
|
Service Code
|
CPT 14001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$8,114.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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
|
$7,027.00
|
|
|
Service Code
|
CPT 14000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$7,027.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| 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/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| 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
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 7552
|
| Min. Negotiated Rate |
$4,276.46 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,276.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$5,096.12
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 7551
|
| Min. Negotiated Rate |
$2,916.68 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,916.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$3,475.72
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 7553
|
| Min. Negotiated Rate |
$6,703.68 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,703.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$7,988.55
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 7554
|
| Min. Negotiated Rate |
$11,556.98 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$11,556.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$13,772.07
|
|
|
Adolescent
|
Facility
IP
|
$34,005.88
|
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
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 |
$898.10 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$3,367.86
|
| Rate for Payer: Blue Shield of California EPN |
$2,397.92
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Central Health Plan Commercial |
$3,592.38
|
| 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: Health Management Network EPO/PPO |
$4,041.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,995.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$898.10
|
| Rate for Payer: Multiplan Commercial |
$3,367.86
|
| Rate for Payer: Networks By Design Commercial |
$2,245.24
|
| Rate for Payer: Prime Health Services Commercial |
$3,816.91
|
|
|
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 |
$4,041.43 |
| Rate for Payer: Adventist Health Medi-Cal |
$38.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$237.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$54.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.11
|
| Rate for Payer: BCBS Transplant Transplant |
$2,694.29
|
| Rate for Payer: Blue Shield of California Commercial |
$41.64
|
| Rate for Payer: Blue Shield of California EPN |
$37.85
|
| Rate for Payer: Caremore Medicare Advantage |
$38.37
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Central Health Plan Commercial |
$3,592.38
|
| 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: 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 Management Network EPO/PPO |
$4,041.43
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3,367.86
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$62.92
|
| Rate for Payer: IEHP medi-cal |
$63.31
|
| Rate for Payer: IEHP Medicare Advantage |
$38.37
|
| Rate for Payer: Innovage PACE Commercial |
$57.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,995.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$898.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$51.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.41
|
| Rate for Payer: Multiplan Commercial |
$3,367.86
|
| Rate for Payer: Networks By Design Commercial |
$2,245.24
|
| Rate for Payer: Prime Health Services Commercial |
$3,816.91
|
| Rate for Payer: Prime Health Services Medicare |
$40.67
|
| Rate for Payer: Riverside University Health MISP |
$42.20
|
| 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 |
$1,436.95 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5,388.57
|
| Rate for Payer: Blue Shield of California EPN |
$3,836.66
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Central Health Plan Commercial |
$5,747.81
|
| 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: Health Management Network EPO/PPO |
$6,466.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,792.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,436.95
|
| Rate for Payer: Multiplan Commercial |
$5,388.57
|
| Rate for Payer: Networks By Design Commercial |
$3,592.38
|
| Rate for Payer: Prime Health Services Commercial |
$6,107.05
|
|
|
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 |
$6,466.28 |
| Rate for Payer: Adventist Health Medi-Cal |
$38.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$237.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$54.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.11
|
| Rate for Payer: BCBS Transplant Transplant |
$4,310.86
|
| Rate for Payer: Blue Shield of California Commercial |
$41.64
|
| Rate for Payer: Blue Shield of California EPN |
$37.85
|
| Rate for Payer: Caremore Medicare Advantage |
$38.37
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Central Health Plan Commercial |
$5,747.81
|
| 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: 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 Management Network EPO/PPO |
$6,466.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5,388.57
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$62.92
|
| Rate for Payer: IEHP medi-cal |
$63.31
|
| Rate for Payer: IEHP Medicare Advantage |
$38.37
|
| Rate for Payer: Innovage PACE Commercial |
$57.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4,792.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,436.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$51.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$51.41
|
| Rate for Payer: Multiplan Commercial |
$5,388.57
|
| Rate for Payer: Networks By Design Commercial |
$3,592.38
|
| Rate for Payer: Prime Health Services Commercial |
$6,107.05
|
| Rate for Payer: Prime Health Services Medicare |
$40.67
|
| Rate for Payer: Riverside University Health MISP |
$42.20
|
| 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 AND PITUITARY PROCEDURES WITH CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 614
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 615
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 4012
|
| Min. Negotiated Rate |
$22,826.11 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,826.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$27,201.12
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 4011
|
| Min. Negotiated Rate |
$12,953.72 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,953.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$15,436.52
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$57,313.34
|
|
|
Service Code
|
APR-DRG 4014
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$57,313.34 |
| Rate for Payer: Adventist Health Medi-Cal |
$48,095.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$57,313.34
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$34,135.20
|
|
|
Service Code
|
APR-DRG 4013
|
| Min. Negotiated Rate |
$28,644.92 |
| Max. Negotiated Rate |
$34,135.20 |
| Rate for Payer: Adventist Health Medi-Cal |
$28,644.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$34,135.20
|
|
|
Adult
|
Facility
IP
|
$34,005.88
|
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
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 |
$8,880.00 |
| Max. Negotiated Rate |
$39,960.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$33,300.00
|
| Rate for Payer: Blue Shield of California EPN |
$23,709.60
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Central Health Plan Commercial |
$35,520.00
|
| 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: Health Management Network EPO/PPO |
$39,960.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$29,614.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,880.00
|
| Rate for Payer: Multiplan Commercial |
$33,300.00
|
| Rate for Payer: Networks By Design Commercial |
$22,200.00
|
| Rate for Payer: Prime Health Services Commercial |
$37,740.00
|
|
|
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 |
$39,960.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$862.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5,343.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,077.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$948.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$948.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,830.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,004.33
|
| Rate for Payer: BCBS Transplant Transplant |
$26,640.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,221.00
|
| Rate for Payer: Blue Shield of California EPN |
$1,110.00
|
| Rate for Payer: Caremore Medicare Advantage |
$862.28
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Cash Price |
$19,980.00
|
| Rate for Payer: Central Health Plan Commercial |
$35,520.00
|
| 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: 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 Management Network EPO/PPO |
$39,960.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$33,300.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,414.14
|
| Rate for Payer: IEHP medi-cal |
$1,422.76
|
| Rate for Payer: IEHP Medicare Advantage |
$862.28
|
| Rate for Payer: Innovage PACE Commercial |
$1,293.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$29,614.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$862.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,880.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,155.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,155.46
|
| Rate for Payer: Multiplan Commercial |
$33,300.00
|
| Rate for Payer: Networks By Design Commercial |
$22,200.00
|
| Rate for Payer: Prime Health Services Commercial |
$37,740.00
|
| Rate for Payer: Prime Health Services Medicare |
$914.02
|
| Rate for Payer: Riverside University Health MISP |
$948.51
|
| 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
|
|
