|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
|
OP
|
$13,764.00
|
|
|
Service Code
|
HCPCS J9153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$272.89 |
| Max. Negotiated Rate |
$12,387.60 |
| Rate for Payer: Adventist Health Commercial |
$2,752.80
|
| Rate for Payer: Adventist Health Medi-Cal |
$272.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$490.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$409.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$300.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$272.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$359.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$448.05
|
| Rate for Payer: Blue Shield of California Commercial |
$313.65
|
| Rate for Payer: Blue Shield of California EPN |
$285.14
|
| Rate for Payer: Cash Price |
$6,193.80
|
| Rate for Payer: Cash Price |
$6,193.80
|
| Rate for Payer: Central Health Plan Commercial |
$11,011.20
|
| Rate for Payer: Cigna of CA HMO |
$9,634.80
|
| Rate for Payer: Cigna of CA PPO |
$9,634.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$300.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$300.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9,634.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$450.27
|
| Rate for Payer: EPIC Health Plan Senior |
$300.18
|
| Rate for Payer: Galaxy Health WC |
$11,699.40
|
| Rate for Payer: Global Benefits Group Commercial |
$8,258.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$12,387.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$447.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$272.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$272.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8,740.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$494.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$382.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,752.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$365.67
|
| Rate for Payer: Multiplan Commercial |
$10,323.00
|
| Rate for Payer: Networks By Design Commercial |
$6,882.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$272.89
|
| Rate for Payer: Prime Health Services Commercial |
$11,699.40
|
| Rate for Payer: Prime Health Services Medicare |
$289.26
|
| Rate for Payer: Riverside University Health System MISP |
$300.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8,258.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8,258.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,165.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5,027.99
|
| Rate for Payer: United Healthcare HMO Rider |
$4,919.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,507.71
|
| Rate for Payer: Upland Medical Group Pediatric |
$272.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$341.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$300.18
|
| Rate for Payer: Vantage Medical Group Senior |
$300.18
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
|
IP
|
$13,764.00
|
|
|
Service Code
|
HCPCS J9153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,752.80 |
| Max. Negotiated Rate |
$12,387.60 |
| Rate for Payer: Adventist Health Commercial |
$2,752.80
|
| Rate for Payer: Blue Shield of California Commercial |
$11,038.73
|
| Rate for Payer: Blue Shield of California EPN |
$6,937.06
|
| Rate for Payer: Cash Price |
$6,193.80
|
| Rate for Payer: Central Health Plan Commercial |
$11,011.20
|
| Rate for Payer: Cigna of CA HMO |
$9,634.80
|
| Rate for Payer: Cigna of CA PPO |
$9,634.80
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9,634.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,505.60
|
| Rate for Payer: EPIC Health Plan Senior |
$5,505.60
|
| Rate for Payer: Galaxy Health WC |
$11,699.40
|
| Rate for Payer: Global Benefits Group Commercial |
$8,258.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$12,387.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8,740.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,120.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,752.80
|
| Rate for Payer: Multiplan Commercial |
$10,323.00
|
| Rate for Payer: Networks By Design Commercial |
$6,882.00
|
| Rate for Payer: Prime Health Services Commercial |
$11,699.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,165.63
|
| Rate for Payer: United Healthcare All Other HMO |
$5,027.99
|
| Rate for Payer: United Healthcare HMO Rider |
$4,919.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,507.71
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
|
OP
|
$37.08
|
|
|
Service Code
|
HCPCS J9150
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$192.73 |
| Rate for Payer: Adventist Health Commercial |
$7.42
|
| Rate for Payer: Adventist Health Commercial |
$7.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$51.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$51.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$154.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$154.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$192.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$192.73
|
| Rate for Payer: Blue Shield of California Commercial |
$87.16
|
| Rate for Payer: Blue Shield of California Commercial |
$87.16
|
| Rate for Payer: Blue Shield of California EPN |
$79.24
|
| Rate for Payer: Blue Shield of California EPN |
$79.24
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$16.69
|
| Rate for Payer: Cash Price |
$16.69
|
| Rate for Payer: Central Health Plan Commercial |
$29.66
|
| Rate for Payer: Central Health Plan Commercial |
$31.47
|
| Rate for Payer: Cigna of CA HMO |
$25.96
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$25.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$33.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.74
|
| Rate for Payer: EPIC Health Plan Senior |
$14.83
|
| Rate for Payer: EPIC Health Plan Senior |
$15.74
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Galaxy Health WC |
$31.52
|
| Rate for Payer: Global Benefits Group Commercial |
$22.25
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.81
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$24.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27.54
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: Multiplan Commercial |
$27.81
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Networks By Design Commercial |
$18.54
|
| Rate for Payer: Prime Health Services Commercial |
$31.52
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
| Rate for Payer: Riverside University Health System MISP |
$15.74
|
| Rate for Payer: Riverside University Health System MISP |
$14.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$22.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$22.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.76
|
| Rate for Payer: United Healthcare All Other HMO |
$14.37
|
| Rate for Payer: United Healthcare All Other HMO |
$13.55
|
| Rate for Payer: United Healthcare HMO Rider |
$13.25
|
| Rate for Payer: United Healthcare HMO Rider |
$14.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.44
|
| Rate for Payer: Vantage Medical Group Senior |
$33.44
|
| Rate for Payer: Vantage Medical Group Senior |
$31.52
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
|
IP
|
$39.34
|
|
|
Service Code
|
HCPCS J9150
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Adventist Health Commercial |
$7.87
|
| Rate for Payer: Adventist Health Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California Commercial |
$31.55
|
| Rate for Payer: Blue Shield of California Commercial |
$29.74
|
| Rate for Payer: Blue Shield of California EPN |
$18.69
|
| Rate for Payer: Blue Shield of California EPN |
$19.83
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$16.69
|
| Rate for Payer: Central Health Plan Commercial |
$31.47
|
| Rate for Payer: Central Health Plan Commercial |
$29.66
|
| Rate for Payer: Cigna of CA HMO |
$25.96
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$25.96
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.96
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.74
|
| Rate for Payer: EPIC Health Plan Senior |
$14.83
|
| Rate for Payer: EPIC Health Plan Senior |
$15.74
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Galaxy Health WC |
$31.52
|
| Rate for Payer: Global Benefits Group Commercial |
$22.25
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$33.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$24.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$23.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.42
|
| Rate for Payer: Multiplan Commercial |
$27.81
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: Networks By Design Commercial |
$18.54
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
| Rate for Payer: Prime Health Services Commercial |
$31.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.76
|
| Rate for Payer: United Healthcare All Other HMO |
$14.37
|
| Rate for Payer: United Healthcare All Other HMO |
$13.55
|
| Rate for Payer: United Healthcare HMO Rider |
$13.25
|
| Rate for Payer: United Healthcare HMO Rider |
$14.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.88
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC
|
Facility
|
IP
|
$53,930.26
|
|
|
Service Code
|
MSDRG 744
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$53,930.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53,930.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$34,836.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48,772.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$48,118.79
|
| Rate for Payer: EPIC Health Plan Senior |
$32,079.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29,162.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40,828.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39,078.29
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29,162.90
|
| Rate for Payer: Prime Health Services Medicare |
$30,912.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC
|
Facility
|
IP
|
$29,937.86
|
|
|
Service Code
|
MSDRG 745
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$29,937.86 |
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$29,937.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19,338.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,074.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$27,373.58
|
| Rate for Payer: EPIC Health Plan Senior |
$18,249.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,590.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,226.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,230.67
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$16,590.05
|
| Rate for Payer: Prime Health Services Medicare |
$17,585.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,124.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,124.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,280.13
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,336.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,124.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,504.98
|
| Rate for Payer: EPIC Health Plan Senior |
$2,336.65
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,483.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$348.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,124.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$384.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,973.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,846.47
|
| Rate for Payer: Multiplan WC |
$3,280.13
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,124.23
|
| Rate for Payer: Preferred Health Network WC |
$3,347.07
|
| Rate for Payer: Prime Health Services Medicare |
$2,251.68
|
| Rate for Payer: Prime Health Services WC |
$3,246.66
|
| Rate for Payer: Riverside University Health System MISP |
$2,336.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,460.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,591.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,374.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,124.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2,124.23
|
|
|
DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11046
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.78 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$53.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$59.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$950.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$1,239.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,568.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1,045.63
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,558.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$269.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$297.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,330.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$950.57
|
| Rate for Payer: Preferred Health Network WC |
$1,264.53
|
| Rate for Payer: Prime Health Services Medicare |
$1,007.60
|
| Rate for Payer: Prime Health Services WC |
$1,226.59
|
| Rate for Payer: Riverside University Health System MISP |
$1,045.63
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$950.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3,974.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,523.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$24.97
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
|
|
DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 11042
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$178.66 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$522.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$522.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,587.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$808.84
|
| Rate for Payer: Blue Shield of California Commercial |
$4,407.11
|
| Rate for Payer: Blue Shield of California EPN |
$3,165.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$784.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$575.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$522.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$862.70
|
| Rate for Payer: EPIC Health Plan Senior |
$575.13
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$857.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$178.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$522.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$197.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$731.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$700.62
|
| Rate for Payer: Multiplan WC |
$808.84
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$522.85
|
| Rate for Payer: Preferred Health Network WC |
$825.35
|
| Rate for Payer: Prime Health Services Medicare |
$554.22
|
| Rate for Payer: Prime Health Services WC |
$800.59
|
| Rate for Payer: Riverside University Health System MISP |
$575.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,593.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,093.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,000.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$522.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Vantage Medical Group Senior |
$522.85
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
|
OP
|
$2,160.04
|
|
|
Service Code
|
NDC 6484207279
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$432.01 |
| Max. Negotiated Rate |
$1,944.04 |
| Rate for Payer: Adventist Health Commercial |
$432.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,311.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,836.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,188.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,620.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,045.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,256.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1,369.47
|
| Rate for Payer: Blue Shield of California EPN |
$861.86
|
| Rate for Payer: Cash Price |
$972.02
|
| Rate for Payer: Central Health Plan Commercial |
$1,728.03
|
| Rate for Payer: Cigna of CA HMO |
$1,512.03
|
| Rate for Payer: Cigna of CA PPO |
$1,512.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,836.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,836.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,836.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,512.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$864.02
|
| Rate for Payer: EPIC Health Plan Senior |
$864.02
|
| Rate for Payer: Galaxy Health WC |
$1,836.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1,296.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,944.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,371.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$784.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,274.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$432.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,512.03
|
| Rate for Payer: Multiplan Commercial |
$1,620.03
|
| Rate for Payer: Networks By Design Commercial |
$1,404.03
|
| Rate for Payer: Prime Health Services Commercial |
$1,836.03
|
| Rate for Payer: Riverside University Health System MISP |
$864.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,296.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,296.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,080.02
|
| Rate for Payer: United Healthcare All Other HMO |
$1,080.02
|
| Rate for Payer: United Healthcare HMO Rider |
$1,080.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,080.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,836.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,836.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1,836.03
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
|
IP
|
$2,160.04
|
|
|
Service Code
|
NDC 6484207279
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$432.01 |
| Max. Negotiated Rate |
$1,944.04 |
| Rate for Payer: Adventist Health Commercial |
$432.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1,732.35
|
| Rate for Payer: Blue Shield of California EPN |
$1,088.66
|
| Rate for Payer: Cash Price |
$972.02
|
| Rate for Payer: Central Health Plan Commercial |
$1,728.03
|
| Rate for Payer: Cigna of CA HMO |
$1,512.03
|
| Rate for Payer: Cigna of CA PPO |
$1,512.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,512.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$864.02
|
| Rate for Payer: EPIC Health Plan Senior |
$864.02
|
| Rate for Payer: Galaxy Health WC |
$1,836.03
|
| Rate for Payer: Global Benefits Group Commercial |
$1,296.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,944.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,371.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,274.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$432.01
|
| Rate for Payer: Multiplan Commercial |
$1,620.03
|
| Rate for Payer: Networks By Design Commercial |
$1,404.03
|
| Rate for Payer: Prime Health Services Commercial |
$1,836.03
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
OP
|
$237.60
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$213.84 |
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.47
|
| 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 |
$489.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$316.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$432.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$178.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$49.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$49.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$49.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.79
|
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California EPN |
$7.57
|
| Rate for Payer: Blue Shield of California EPN |
$7.57
|
| Rate for Payer: Blue Shield of California EPN |
$7.57
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Central Health Plan Commercial |
$96.00
|
| Rate for Payer: Central Health Plan Commercial |
$190.08
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$489.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$489.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$201.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$489.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$166.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$95.04
|
| Rate for Payer: EPIC Health Plan Senior |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$213.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$150.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$76.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$140.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$166.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$403.20
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| 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 |
$288.00
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Riverside University Health System MISP |
$95.04
|
| Rate for Payer: Riverside University Health System MISP |
$230.40
|
| Rate for Payer: Riverside University Health System MISP |
$48.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$345.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$345.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$89.17
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare All Other HMO |
$86.80
|
| Rate for Payer: United Healthcare All Other HMO |
$43.84
|
| Rate for Payer: United Healthcare HMO Rider |
$84.92
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare HMO Rider |
$42.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$77.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$489.60
|
| 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 Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$489.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$489.60
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Adventist Health Commercial |
$115.20
|
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Blue Shield of California Commercial |
$461.95
|
| Rate for Payer: Blue Shield of California Commercial |
$190.56
|
| Rate for Payer: Blue Shield of California Commercial |
$96.24
|
| Rate for Payer: Blue Shield of California EPN |
$60.48
|
| Rate for Payer: Blue Shield of California EPN |
$290.30
|
| Rate for Payer: Blue Shield of California EPN |
$119.75
|
| Rate for Payer: Cash Price |
$259.20
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Central Health Plan Commercial |
$190.08
|
| Rate for Payer: Central Health Plan Commercial |
$96.00
|
| Rate for Payer: Central Health Plan Commercial |
$460.80
|
| Rate for Payer: Cigna of CA HMO |
$403.20
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$403.20
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$403.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$166.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$84.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$230.40
|
| Rate for Payer: EPIC Health Plan Senior |
$95.04
|
| Rate for Payer: EPIC Health Plan Senior |
$48.00
|
| Rate for Payer: EPIC Health Plan Senior |
$230.40
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$489.60
|
| Rate for Payer: Global Benefits Group Commercial |
$345.60
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$518.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$213.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$76.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$365.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$150.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$339.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$140.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$115.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Networks By Design Commercial |
$288.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$489.60
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$216.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$89.17
|
| Rate for Payer: United Healthcare All Other HMO |
$86.80
|
| Rate for Payer: United Healthcare All Other HMO |
$43.84
|
| Rate for Payer: United Healthcare All Other HMO |
$210.41
|
| Rate for Payer: United Healthcare HMO Rider |
$42.89
|
| Rate for Payer: United Healthcare HMO Rider |
$84.92
|
| Rate for Payer: United Healthcare HMO Rider |
$205.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$77.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$188.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.30
|
|
|
DECOMPRESSION, PERCUTANEOUS, WITH PARTIAL REMOVAL OF THE LIGAMENTUM FLAVUM, INCLUDING LAMINOTOMY FOR ACCESS, EPIDUROGRAPHY, AND IMAGING GUIDANCE (IE, CT OR FLUOROSCOPY), BILATERAL; ADDITIONAL INTERSPACE(S), LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 62331
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,113.68 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
|
|
DECOMPRESSION, PERCUTANEOUS, WITH PARTIAL REMOVAL OF THE LIGAMENTUM FLAVUM, INCLUDING LAMINOTOMY FOR ACCESS, EPIDUROGRAPHY, AND IMAGING GUIDANCE (IE, CT OR FLUOROSCOPY), BILATERAL; ONE INTERSPACE, LUMBAR
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 62330
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,113.68 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Prime Health Services Medicare |
$9,892.66
|
| Rate for Payer: Adventist Health Medi-Cal |
$9,332.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9,332.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,687.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,136.21
|
| Rate for Payer: Blue Shield of California EPN |
$5,113.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,265.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,332.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,398.95
|
| Rate for Payer: EPIC Health Plan Senior |
$10,265.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$15,305.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,332.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,065.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,505.82
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$9,332.70
|
| Rate for Payer: Riverside University Health System MISP |
$10,265.97
|
| Rate for Payer: Upland Medical Group Pediatric |
$9,332.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Vantage Medical Group Senior |
$9,332.70
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
IP
|
$145.49
|
|
|
Service Code
|
NDC 0078065515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$130.94 |
| Rate for Payer: Adventist Health Commercial |
$29.10
|
| Rate for Payer: Blue Shield of California Commercial |
$116.68
|
| Rate for Payer: Blue Shield of California EPN |
$73.33
|
| Rate for Payer: Cash Price |
$65.47
|
| Rate for Payer: Central Health Plan Commercial |
$116.39
|
| Rate for Payer: Cigna of CA HMO |
$101.84
|
| Rate for Payer: Cigna of CA PPO |
$101.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.20
|
| Rate for Payer: EPIC Health Plan Senior |
$58.20
|
| Rate for Payer: Galaxy Health WC |
$123.67
|
| Rate for Payer: Global Benefits Group Commercial |
$87.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$92.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.10
|
| Rate for Payer: Multiplan Commercial |
$109.12
|
| Rate for Payer: Networks By Design Commercial |
$94.57
|
| Rate for Payer: Prime Health Services Commercial |
$123.67
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
|
OP
|
$145.49
|
|
|
Service Code
|
NDC 0078065515
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$130.94 |
| Rate for Payer: Adventist Health Commercial |
$29.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$88.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$123.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$109.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$70.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.63
|
| Rate for Payer: Blue Shield of California Commercial |
$92.24
|
| Rate for Payer: Blue Shield of California EPN |
$58.05
|
| Rate for Payer: Cash Price |
$65.47
|
| Rate for Payer: Central Health Plan Commercial |
$116.39
|
| Rate for Payer: Cigna of CA HMO |
$101.84
|
| Rate for Payer: Cigna of CA PPO |
$101.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$123.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$123.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$123.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$101.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.20
|
| Rate for Payer: EPIC Health Plan Senior |
$58.20
|
| Rate for Payer: Galaxy Health WC |
$123.67
|
| Rate for Payer: Global Benefits Group Commercial |
$87.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$130.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$92.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$52.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$85.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$101.84
|
| Rate for Payer: Multiplan Commercial |
$109.12
|
| Rate for Payer: Networks By Design Commercial |
$94.57
|
| Rate for Payer: Prime Health Services Commercial |
$123.67
|
| Rate for Payer: Riverside University Health System MISP |
$58.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$87.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$87.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$72.75
|
| Rate for Payer: United Healthcare All Other HMO |
$72.75
|
| Rate for Payer: United Healthcare HMO Rider |
$72.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$123.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$123.67
|
| Rate for Payer: Vantage Medical Group Senior |
$123.67
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
OP
|
$127.17
|
|
|
Service Code
|
NDC 0078046915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.43 |
| Max. Negotiated Rate |
$114.45 |
| Rate for Payer: Adventist Health Commercial |
$25.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$77.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$108.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$61.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.97
|
| Rate for Payer: Blue Shield of California Commercial |
$80.63
|
| Rate for Payer: Blue Shield of California EPN |
$50.74
|
| Rate for Payer: Cash Price |
$57.23
|
| Rate for Payer: Central Health Plan Commercial |
$101.74
|
| Rate for Payer: Cigna of CA HMO |
$89.02
|
| Rate for Payer: Cigna of CA PPO |
$89.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$108.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$89.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.87
|
| Rate for Payer: EPIC Health Plan Senior |
$50.87
|
| Rate for Payer: Galaxy Health WC |
$108.09
|
| Rate for Payer: Global Benefits Group Commercial |
$76.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$114.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$80.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$46.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$75.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$89.02
|
| Rate for Payer: Multiplan Commercial |
$95.38
|
| Rate for Payer: Networks By Design Commercial |
$82.66
|
| Rate for Payer: Prime Health Services Commercial |
$108.09
|
| Rate for Payer: Riverside University Health System MISP |
$50.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$76.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$76.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$63.59
|
| Rate for Payer: United Healthcare All Other HMO |
$63.59
|
| Rate for Payer: United Healthcare HMO Rider |
$63.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$63.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$108.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.09
|
| Rate for Payer: Vantage Medical Group Senior |
$108.09
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
|
IP
|
$127.17
|
|
|
Service Code
|
NDC 0078046915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.43 |
| Max. Negotiated Rate |
$114.45 |
| Rate for Payer: Adventist Health Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California Commercial |
$101.99
|
| Rate for Payer: Blue Shield of California EPN |
$64.09
|
| Rate for Payer: Cash Price |
$57.23
|
| Rate for Payer: Central Health Plan Commercial |
$101.74
|
| Rate for Payer: Cigna of CA HMO |
$89.02
|
| Rate for Payer: Cigna of CA PPO |
$89.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$89.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.87
|
| Rate for Payer: EPIC Health Plan Senior |
$50.87
|
| Rate for Payer: Galaxy Health WC |
$108.09
|
| Rate for Payer: Global Benefits Group Commercial |
$76.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$114.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$80.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$75.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.43
|
| Rate for Payer: Multiplan Commercial |
$95.38
|
| Rate for Payer: Networks By Design Commercial |
$82.66
|
| Rate for Payer: Prime Health Services Commercial |
$108.09
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
OP
|
$290.97
|
|
|
Service Code
|
NDC 0078065615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.19 |
| Max. Negotiated Rate |
$261.87 |
| Rate for Payer: Adventist Health Commercial |
$58.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$247.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$160.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$218.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$140.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$169.26
|
| Rate for Payer: Blue Shield of California Commercial |
$184.47
|
| Rate for Payer: Blue Shield of California EPN |
$116.10
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Central Health Plan Commercial |
$232.78
|
| Rate for Payer: Cigna of CA HMO |
$203.68
|
| Rate for Payer: Cigna of CA PPO |
$203.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$247.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$247.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$247.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$203.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.39
|
| Rate for Payer: EPIC Health Plan Senior |
$116.39
|
| Rate for Payer: Galaxy Health WC |
$247.32
|
| Rate for Payer: Global Benefits Group Commercial |
$174.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$261.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$184.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$105.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$203.68
|
| Rate for Payer: Multiplan Commercial |
$218.23
|
| Rate for Payer: Networks By Design Commercial |
$189.13
|
| Rate for Payer: Prime Health Services Commercial |
$247.32
|
| Rate for Payer: Riverside University Health System MISP |
$116.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$174.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$174.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$145.49
|
| Rate for Payer: United Healthcare All Other HMO |
$145.49
|
| Rate for Payer: United Healthcare HMO Rider |
$145.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$145.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$247.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$247.32
|
| Rate for Payer: Vantage Medical Group Senior |
$247.32
|
|
|
DEFERASIROX 360 MG TABLET [206428]
|
Facility
|
IP
|
$290.97
|
|
|
Service Code
|
NDC 0078065615
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.19 |
| Max. Negotiated Rate |
$261.87 |
| Rate for Payer: Adventist Health Commercial |
$58.19
|
| Rate for Payer: Blue Shield of California Commercial |
$233.36
|
| Rate for Payer: Blue Shield of California EPN |
$146.65
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Central Health Plan Commercial |
$232.78
|
| Rate for Payer: Cigna of CA HMO |
$203.68
|
| Rate for Payer: Cigna of CA PPO |
$203.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$203.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.39
|
| Rate for Payer: EPIC Health Plan Senior |
$116.39
|
| Rate for Payer: Galaxy Health WC |
$247.32
|
| Rate for Payer: Global Benefits Group Commercial |
$174.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$261.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$184.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.19
|
| Rate for Payer: Multiplan Commercial |
$218.23
|
| Rate for Payer: Networks By Design Commercial |
$189.13
|
| Rate for Payer: Prime Health Services Commercial |
$247.32
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
IP
|
$254.34
|
|
|
Service Code
|
NDC 0078047015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$228.91 |
| Rate for Payer: Adventist Health Commercial |
$50.87
|
| Rate for Payer: Blue Shield of California Commercial |
$203.98
|
| Rate for Payer: Blue Shield of California EPN |
$128.19
|
| Rate for Payer: Cash Price |
$114.45
|
| Rate for Payer: Central Health Plan Commercial |
$203.47
|
| Rate for Payer: Cigna of CA HMO |
$178.04
|
| Rate for Payer: Cigna of CA PPO |
$178.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$178.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.74
|
| Rate for Payer: EPIC Health Plan Senior |
$101.74
|
| Rate for Payer: Galaxy Health WC |
$216.19
|
| Rate for Payer: Global Benefits Group Commercial |
$152.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$228.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$161.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$150.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.87
|
| Rate for Payer: Multiplan Commercial |
$190.75
|
| Rate for Payer: Networks By Design Commercial |
$165.32
|
| Rate for Payer: Prime Health Services Commercial |
$216.19
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
|
OP
|
$254.34
|
|
|
Service Code
|
NDC 0078047015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$228.91 |
| Rate for Payer: Adventist Health Commercial |
$50.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$154.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$216.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$139.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$190.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$123.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$147.95
|
| Rate for Payer: Blue Shield of California Commercial |
$161.25
|
| Rate for Payer: Blue Shield of California EPN |
$101.48
|
| Rate for Payer: Cash Price |
$114.45
|
| Rate for Payer: Central Health Plan Commercial |
$203.47
|
| Rate for Payer: Cigna of CA HMO |
$178.04
|
| Rate for Payer: Cigna of CA PPO |
$178.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$216.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$216.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$216.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$178.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$101.74
|
| Rate for Payer: EPIC Health Plan Senior |
$101.74
|
| Rate for Payer: Galaxy Health WC |
$216.19
|
| Rate for Payer: Global Benefits Group Commercial |
$152.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$228.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$161.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$92.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$150.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$178.04
|
| Rate for Payer: Multiplan Commercial |
$190.75
|
| Rate for Payer: Networks By Design Commercial |
$165.32
|
| Rate for Payer: Prime Health Services Commercial |
$216.19
|
| Rate for Payer: Riverside University Health System MISP |
$101.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$152.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$152.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$127.17
|
| Rate for Payer: United Healthcare All Other HMO |
$127.17
|
| Rate for Payer: United Healthcare HMO Rider |
$127.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$127.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$216.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$216.19
|
| Rate for Payer: Vantage Medical Group Senior |
$216.19
|
|
