|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 4988406601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 6498027301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 6498027301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 2315560701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 4988406601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Senior |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 5511164901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Central Health Plan Commercial |
$1.42
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Senior |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.33
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 1310701501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994080432
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Central Health Plan Commercial |
$2.10
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994080432
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Adventist Health Commercial |
$0.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.05
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Central Health Plan Commercial |
$2.10
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Senior |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Riverside University Health System MISP |
$1.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.31
|
| Rate for Payer: United Healthcare All Other HMO |
$1.31
|
| Rate for Payer: United Healthcare HMO Rider |
$1.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
IP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.95 |
| Max. Negotiated Rate |
$539.78 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Blue Shield of California Commercial |
$481.01
|
| Rate for Payer: Blue Shield of California EPN |
$302.28
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Central Health Plan Commercial |
$479.81
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Senior |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$539.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$380.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$353.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.95
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.09
|
| Rate for Payer: United Healthcare All Other HMO |
$219.09
|
| Rate for Payer: United Healthcare HMO Rider |
$214.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.42
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$539.78 |
| Rate for Payer: Adventist Health Commercial |
$119.95
|
| Rate for Payer: Adventist Health Medi-Cal |
$11.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$66.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$45.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.83
|
| Rate for Payer: Blue Shield of California Commercial |
$52.78
|
| Rate for Payer: Blue Shield of California EPN |
$47.98
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Central Health Plan Commercial |
$479.81
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.22
|
| Rate for Payer: EPIC Health Plan Senior |
$12.14
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$539.78
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$18.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$11.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$380.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.79
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$11.04
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: Prime Health Services Medicare |
$11.70
|
| Rate for Payer: Riverside University Health System MISP |
$12.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$359.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$359.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.09
|
| Rate for Payer: United Healthcare All Other HMO |
$219.09
|
| Rate for Payer: United Healthcare HMO Rider |
$214.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.42
|
| Rate for Payer: Upland Medical Group Pediatric |
$11.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.14
|
| Rate for Payer: Vantage Medical Group Senior |
$12.14
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$769.92
|
| Rate for Payer: Blue Shield of California EPN |
$483.84
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$566.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
HCPCS J1429
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$977.79 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$977.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$720.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$316.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$395.16
|
| Rate for Payer: Blue Shield of California Commercial |
$211.20
|
| Rate for Payer: Blue Shield of California EPN |
$192.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$816.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$816.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$816.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$282.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$609.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$566.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$672.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Riverside University Health System MISP |
$384.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$816.00
|
| Rate for Payer: Vantage Medical Group Senior |
$816.00
|
|
|
GONIOTOMY
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.36 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,316.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,974.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,847.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,316.27
|
| 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 |
$8,144.17
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,974.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,847.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,316.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,771.85
|
| Rate for Payer: EPIC Health Plan Senior |
$5,847.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,718.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$145.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,316.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$160.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,442.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7,123.80
|
| Rate for Payer: Multiplan WC |
$8,144.17
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$5,316.27
|
| Rate for Payer: Preferred Health Network WC |
$8,310.38
|
| Rate for Payer: Prime Health Services Medicare |
$5,635.25
|
| Rate for Payer: Prime Health Services WC |
$8,061.07
|
| Rate for Payer: Riverside University Health System MISP |
$5,847.90
|
| Rate for Payer: United Healthcare All Other HMO |
$16,122.00
|
| Rate for Payer: United Healthcare HMO Rider |
$10,165.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9,312.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$5,316.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,974.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,847.90
|
| Rate for Payer: Vantage Medical Group Senior |
$5,316.27
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
IP
|
$3,855.49
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$771.10 |
| Max. Negotiated Rate |
$3,469.94 |
| Rate for Payer: Adventist Health Commercial |
$771.10
|
| Rate for Payer: Blue Shield of California Commercial |
$3,092.10
|
| Rate for Payer: Blue Shield of California EPN |
$1,943.17
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Central Health Plan Commercial |
$3,084.39
|
| Rate for Payer: Cigna of CA HMO |
$2,698.84
|
| Rate for Payer: Cigna of CA PPO |
$2,698.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,698.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,542.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,542.20
|
| Rate for Payer: Galaxy Health WC |
$3,277.17
|
| Rate for Payer: Global Benefits Group Commercial |
$2,313.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,469.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,448.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,274.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$771.10
|
| Rate for Payer: Multiplan Commercial |
$2,891.62
|
| Rate for Payer: Networks By Design Commercial |
$1,927.74
|
| Rate for Payer: Prime Health Services Commercial |
$3,277.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,446.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1,408.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1,377.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,262.67
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
OP
|
$3,855.49
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$771.10 |
| Max. Negotiated Rate |
$3,469.94 |
| Rate for Payer: Adventist Health Commercial |
$771.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,388.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,120.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,891.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$861.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,074.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1,267.66
|
| Rate for Payer: Blue Shield of California EPN |
$1,152.42
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Cash Price |
$1,734.97
|
| Rate for Payer: Central Health Plan Commercial |
$3,084.39
|
| Rate for Payer: Cigna of CA HMO |
$2,698.84
|
| Rate for Payer: Cigna of CA PPO |
$2,698.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,277.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,277.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2,698.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,542.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1,542.20
|
| Rate for Payer: Galaxy Health WC |
$3,277.17
|
| Rate for Payer: Global Benefits Group Commercial |
$2,313.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$3,469.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,337.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2,448.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,477.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,274.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$771.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,698.84
|
| Rate for Payer: Multiplan Commercial |
$2,891.62
|
| Rate for Payer: Networks By Design Commercial |
$1,927.74
|
| Rate for Payer: Prime Health Services Commercial |
$3,277.17
|
| Rate for Payer: Riverside University Health System MISP |
$1,542.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,313.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,313.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,446.97
|
| Rate for Payer: United Healthcare All Other HMO |
$1,408.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1,377.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,262.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,277.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,277.17
|
| Rate for Payer: Vantage Medical Group Senior |
$3,277.17
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
IP
|
$1,414.82
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.96 |
| Max. Negotiated Rate |
$1,273.34 |
| Rate for Payer: Adventist Health Commercial |
$282.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1,134.69
|
| Rate for Payer: Blue Shield of California EPN |
$713.07
|
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Central Health Plan Commercial |
$1,131.86
|
| Rate for Payer: Cigna of CA HMO |
$990.37
|
| Rate for Payer: Cigna of CA PPO |
$990.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$990.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$565.93
|
| Rate for Payer: EPIC Health Plan Senior |
$565.93
|
| Rate for Payer: Galaxy Health WC |
$1,202.60
|
| Rate for Payer: Global Benefits Group Commercial |
$848.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,273.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$898.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$834.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$282.96
|
| Rate for Payer: Multiplan Commercial |
$1,061.12
|
| Rate for Payer: Networks By Design Commercial |
$707.41
|
| Rate for Payer: Prime Health Services Commercial |
$1,202.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$530.98
|
| Rate for Payer: United Healthcare All Other HMO |
$516.83
|
| Rate for Payer: United Healthcare HMO Rider |
$505.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$463.35
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
OP
|
$1,414.82
|
|
|
Service Code
|
HCPCS J9202
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.96 |
| Max. Negotiated Rate |
$1,477.25 |
| Rate for Payer: Adventist Health Commercial |
$282.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,388.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$778.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,061.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$861.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,074.91
|
| Rate for Payer: Blue Shield of California Commercial |
$1,267.66
|
| Rate for Payer: Blue Shield of California EPN |
$1,152.42
|
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Cash Price |
$636.67
|
| Rate for Payer: Central Health Plan Commercial |
$1,131.86
|
| Rate for Payer: Cigna of CA HMO |
$990.37
|
| Rate for Payer: Cigna of CA PPO |
$990.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,202.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,202.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$990.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$565.93
|
| Rate for Payer: EPIC Health Plan Senior |
$565.93
|
| Rate for Payer: Galaxy Health WC |
$1,202.60
|
| Rate for Payer: Global Benefits Group Commercial |
$848.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,273.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,337.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$898.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,477.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$834.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$282.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$990.37
|
| Rate for Payer: Multiplan Commercial |
$1,061.12
|
| Rate for Payer: Networks By Design Commercial |
$707.41
|
| Rate for Payer: Prime Health Services Commercial |
$1,202.60
|
| Rate for Payer: Riverside University Health System MISP |
$565.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$848.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$848.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$530.98
|
| Rate for Payer: United Healthcare All Other HMO |
$516.83
|
| Rate for Payer: United Healthcare HMO Rider |
$505.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$463.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,202.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,202.60
|
| Rate for Payer: Vantage Medical Group Senior |
$1,202.60
|
|
|
GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 21210
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,280.71 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,613.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,924.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$11,976.10
|
| Rate for Payer: Blue Shield of California Commercial |
$9,831.25
|
| Rate for Payer: Blue Shield of California EPN |
$6,179.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,280.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,414.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Preferred Health Network WC |
$12,220.51
|
| Rate for Payer: Prime Health Services Medicare |
$8,070.72
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: Riverside University Health System MISP |
$8,375.28
|
| Rate for Payer: United Healthcare All Other HMO |
$26,788.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,872.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,456.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,613.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$11,976.10
|
| Rate for Payer: Blue Shield of California Commercial |
$9,831.25
|
| Rate for Payer: Blue Shield of California EPN |
$6,179.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,562.92
|
| Rate for Payer: EPIC Health Plan Senior |
$8,375.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$12,486.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$174.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$192.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,659.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Preferred Health Network WC |
$12,220.51
|
| Rate for Payer: Prime Health Services Medicare |
$8,070.72
|
| Rate for Payer: Prime Health Services WC |
$11,853.89
|
| Rate for Payer: Riverside University Health System MISP |
$8,375.28
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$7,613.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING OBTAINING FASCIA)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15840
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,921.07 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Blue Shield of California EPN |
$3,914.40
|
| Rate for Payer: Adventist Health Medi-Cal |
$4,557.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,924.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$7,411.53
|
| Rate for Payer: Blue Shield of California Commercial |
$6,228.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,520.40
|
| Rate for Payer: EPIC Health Plan Senior |
$5,013.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,474.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,921.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,122.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,380.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Preferred Health Network WC |
$7,562.79
|
| Rate for Payer: Prime Health Services Medicare |
$4,831.29
|
| Rate for Payer: Prime Health Services WC |
$7,335.91
|
| Rate for Payer: Riverside University Health System MISP |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,557.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15773
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$892.01 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,653.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$3,703.23
|
| Rate for Payer: Blue Shield of California Commercial |
$3,293.23
|
| Rate for Payer: Blue Shield of California EPN |
$2,069.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,378.64
|
| Rate for Payer: EPIC Health Plan Senior |
$2,919.09
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$4,352.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$892.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$985.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,715.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Preferred Health Network WC |
$3,778.81
|
| Rate for Payer: Prime Health Services Medicare |
$2,812.94
|
| Rate for Payer: Prime Health Services WC |
$3,665.45
|
| Rate for Payer: Riverside University Health System MISP |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO |
$7,378.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,428.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,122.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$2,653.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15771
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$883.68 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,557.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$7,411.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13,231.02
|
| Rate for Payer: Blue Shield of California EPN |
$8,315.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,520.40
|
| Rate for Payer: EPIC Health Plan Senior |
$5,013.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,474.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$883.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$976.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,380.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Preferred Health Network WC |
$7,562.79
|
| Rate for Payer: Prime Health Services Medicare |
$4,831.29
|
| Rate for Payer: Prime Health Services WC |
$7,335.91
|
| Rate for Payer: Riverside University Health System MISP |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,557.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$274.72 |
| 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 |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,074.00
|
| 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 |
$274.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$303.47
|
| 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
|
|
|
GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
|
Facility
|
OP
|
$27,467.00
|
|
|
Service Code
|
CPT 15769
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$145.36 |
| Max. Negotiated Rate |
$27,467.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,557.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$27,467.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,924.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$7,411.53
|
| Rate for Payer: Blue Shield of California Commercial |
$13,231.02
|
| Rate for Payer: Blue Shield of California EPN |
$8,315.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,520.40
|
| Rate for Payer: EPIC Health Plan Senior |
$5,013.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,474.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$145.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$160.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6,380.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Preferred Health Network WC |
$7,562.79
|
| Rate for Payer: Prime Health Services Medicare |
$4,831.29
|
| Rate for Payer: Prime Health Services WC |
$7,335.91
|
| Rate for Payer: Riverside University Health System MISP |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO |
$20,902.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,066.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,971.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$4,557.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
