|
DASATINIB 100 MG TABLET [92897]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Blue Shield of California Commercial |
$516.40
|
| Rate for Payer: Blue Shield of California EPN |
$367.68
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DASATINIB 100 MG TABLET [92897]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0852-22
|
| Hospital Charge Code |
1712498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$418.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$333.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$406.79
|
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Blue Shield of California Commercial |
$433.09
|
| Rate for Payer: Blue Shield of California EPN |
$336.70
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: IEHP medi-cal |
$240.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Riverside University Health MISP |
$275.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Blue Shield of California Commercial |
$516.40
|
| Rate for Payer: Blue Shield of California EPN |
$367.68
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DASATINIB 140 MG TABLET [108422]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0857-22
|
| Hospital Charge Code |
1712499
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$418.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$333.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$406.79
|
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Blue Shield of California Commercial |
$433.09
|
| Rate for Payer: Blue Shield of California EPN |
$336.70
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: IEHP medi-cal |
$240.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Riverside University Health MISP |
$275.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
OP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.20 |
| Max. Negotiated Rate |
$171.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$116.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$92.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$112.85
|
| Rate for Payer: BCBS Transplant Transplant |
$114.61
|
| Rate for Payer: Blue Shield of California Commercial |
$120.15
|
| Rate for Payer: Blue Shield of California EPN |
$93.40
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Central Health Plan Commercial |
$152.81
|
| Rate for Payer: Cigna of CA HMO |
$133.71
|
| Rate for Payer: Cigna of CA PPO |
$133.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.40
|
| Rate for Payer: Galaxy Health WC |
$162.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.91
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$143.26
|
| Rate for Payer: IEHP medi-cal |
$66.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.20
|
| Rate for Payer: Multiplan Commercial |
$143.26
|
| Rate for Payer: Networks By Design Commercial |
$124.16
|
| Rate for Payer: Prime Health Services Commercial |
$162.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$114.61
|
| Rate for Payer: Riverside University Health MISP |
$76.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.50
|
| Rate for Payer: United Healthcare All Other HMO |
$95.50
|
| Rate for Payer: United Healthcare HMO Rider |
$95.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.36
|
| Rate for Payer: Vantage Medical Group Senior |
$162.36
|
|
|
DASATINIB 20 MG TABLET [76717]
|
Facility
IP
|
$191.01
|
|
|
Service Code
|
NDC 0003-0527-11
|
| Hospital Charge Code |
1711976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.20 |
| Max. Negotiated Rate |
$171.91 |
| Rate for Payer: Blue Shield of California Commercial |
$143.26
|
| Rate for Payer: Blue Shield of California EPN |
$102.00
|
| Rate for Payer: Cash Price |
$85.95
|
| Rate for Payer: Central Health Plan Commercial |
$152.81
|
| Rate for Payer: Cigna of CA HMO |
$133.71
|
| Rate for Payer: Cigna of CA PPO |
$133.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.40
|
| Rate for Payer: Galaxy Health WC |
$162.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.20
|
| Rate for Payer: Multiplan Commercial |
$143.26
|
| Rate for Payer: Networks By Design Commercial |
$124.16
|
| Rate for Payer: Prime Health Services Commercial |
$162.36
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
IP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.41 |
| Max. Negotiated Rate |
$343.83 |
| Rate for Payer: Blue Shield of California Commercial |
$286.52
|
| Rate for Payer: Blue Shield of California EPN |
$204.00
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Central Health Plan Commercial |
$305.62
|
| Rate for Payer: Cigna of CA HMO |
$267.42
|
| Rate for Payer: Cigna of CA PPO |
$267.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.81
|
| Rate for Payer: Galaxy Health WC |
$324.73
|
| Rate for Payer: Global Benefits Group Commercial |
$229.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$343.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.41
|
| Rate for Payer: Multiplan Commercial |
$286.52
|
| Rate for Payer: Networks By Design Commercial |
$248.32
|
| Rate for Payer: Prime Health Services Commercial |
$324.73
|
|
|
DASATINIB 70 MG TABLET [76719]
|
Facility
OP
|
$382.03
|
|
|
Service Code
|
NDC 0003-0524-11
|
| Hospital Charge Code |
1711974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.41 |
| Max. Negotiated Rate |
$343.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$232.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$324.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$210.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$184.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$225.70
|
| Rate for Payer: BCBS Transplant Transplant |
$229.22
|
| Rate for Payer: Blue Shield of California Commercial |
$240.30
|
| Rate for Payer: Blue Shield of California EPN |
$186.81
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Central Health Plan Commercial |
$305.62
|
| Rate for Payer: Cigna of CA HMO |
$267.42
|
| Rate for Payer: Cigna of CA PPO |
$267.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$324.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.81
|
| Rate for Payer: EPIC Health Plan Transplant |
$152.81
|
| Rate for Payer: Galaxy Health WC |
$324.73
|
| Rate for Payer: Global Benefits Group Commercial |
$229.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$343.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$286.52
|
| Rate for Payer: IEHP medi-cal |
$133.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$254.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.41
|
| Rate for Payer: Multiplan Commercial |
$286.52
|
| Rate for Payer: Networks By Design Commercial |
$248.32
|
| Rate for Payer: Prime Health Services Commercial |
$324.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$229.22
|
| Rate for Payer: Riverside University Health MISP |
$152.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$229.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$229.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$191.02
|
| Rate for Payer: United Healthcare All Other HMO |
$191.02
|
| Rate for Payer: United Healthcare HMO Rider |
$191.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$191.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$324.73
|
| Rate for Payer: Vantage Medical Group Senior |
$324.73
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
IP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Blue Shield of California Commercial |
$516.40
|
| Rate for Payer: Blue Shield of California EPN |
$367.68
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
|
|
DASATINIB 80 MG TABLET [108421]
|
Facility
OP
|
$688.54
|
|
|
Service Code
|
NDC 0003-0855-22
|
| Hospital Charge Code |
1712500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.71 |
| Max. Negotiated Rate |
$619.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$418.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$585.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$378.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$378.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$333.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$406.79
|
| Rate for Payer: BCBS Transplant Transplant |
$413.12
|
| Rate for Payer: Blue Shield of California Commercial |
$433.09
|
| Rate for Payer: Blue Shield of California EPN |
$336.70
|
| Rate for Payer: Cash Price |
$309.84
|
| Rate for Payer: Central Health Plan Commercial |
$550.83
|
| Rate for Payer: Cigna of CA HMO |
$481.98
|
| Rate for Payer: Cigna of CA PPO |
$481.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$585.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$275.42
|
| Rate for Payer: Galaxy Health WC |
$585.26
|
| Rate for Payer: Global Benefits Group Commercial |
$413.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$619.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$516.40
|
| Rate for Payer: IEHP medi-cal |
$240.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$459.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.71
|
| Rate for Payer: Multiplan Commercial |
$516.40
|
| Rate for Payer: Networks By Design Commercial |
$447.55
|
| Rate for Payer: Prime Health Services Commercial |
$585.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: Riverside University Health MISP |
$275.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$413.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$413.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.27
|
| Rate for Payer: United Healthcare All Other HMO |
$344.27
|
| Rate for Payer: United Healthcare HMO Rider |
$344.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$344.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$585.26
|
| Rate for Payer: Vantage Medical Group Senior |
$585.26
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
IP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,354.40 |
| Max. Negotiated Rate |
$10,594.80 |
| Rate for Payer: Blue Shield of California Commercial |
$8,829.00
|
| Rate for Payer: Blue Shield of California EPN |
$6,286.25
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,417.60
|
| Rate for Payer: Cigna of CA HMO |
$8,240.40
|
| Rate for Payer: Cigna of CA PPO |
$8,240.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,708.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,708.80
|
| Rate for Payer: Galaxy Health WC |
$10,006.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,063.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,594.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,851.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,354.40
|
| Rate for Payer: Multiplan Commercial |
$8,829.00
|
| Rate for Payer: Networks By Design Commercial |
$5,886.00
|
| Rate for Payer: Prime Health Services Commercial |
$10,006.20
|
|
|
DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION [219514]
|
Facility
OP
|
$11,772.00
|
|
|
Service Code
|
CPT J9153
|
| Hospital Charge Code |
ERX219514
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$230.96 |
| Max. Negotiated Rate |
$10,594.80 |
| Rate for Payer: Adventist Health Medi-Cal |
$231.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$456.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$289.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$254.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$359.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$393.11
|
| Rate for Payer: BCBS Transplant Transplant |
$7,063.20
|
| Rate for Payer: Blue Shield of California Commercial |
$254.06
|
| Rate for Payer: Blue Shield of California EPN |
$230.96
|
| Rate for Payer: Caremore Medicare Advantage |
$231.76
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Cash Price |
$5,297.40
|
| Rate for Payer: Central Health Plan Commercial |
$9,417.60
|
| Rate for Payer: Cigna of CA HMO |
$8,240.40
|
| Rate for Payer: Cigna of CA PPO |
$8,240.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$347.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$312.88
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$231.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$231.76
|
| Rate for Payer: Galaxy Health WC |
$10,006.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7,063.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,594.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8,829.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$380.09
|
| Rate for Payer: IEHP medi-cal |
$382.41
|
| Rate for Payer: IEHP Medicare Advantage |
$231.76
|
| Rate for Payer: Innovage PACE Commercial |
$347.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,851.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$231.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,354.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$310.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$310.56
|
| Rate for Payer: Multiplan Commercial |
$8,829.00
|
| Rate for Payer: Networks By Design Commercial |
$5,886.00
|
| Rate for Payer: Prime Health Services Commercial |
$10,006.20
|
| Rate for Payer: Prime Health Services Medicare |
$245.67
|
| Rate for Payer: Riverside University Health MISP |
$254.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,063.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7,063.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,886.00
|
| Rate for Payer: United Healthcare All Other HMO |
$5,886.00
|
| Rate for Payer: United Healthcare HMO Rider |
$5,886.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,886.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$347.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.94
|
| Rate for Payer: Vantage Medical Group Senior |
$231.76
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
OP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Adventist Health Medi-Cal |
$35.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$44.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$39.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$154.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$169.10
|
| Rate for Payer: BCBS Transplant Transplant |
$23.60
|
| Rate for Payer: Blue Shield of California Commercial |
$88.53
|
| Rate for Payer: Blue Shield of California EPN |
$80.48
|
| Rate for Payer: Caremore Medicare Advantage |
$35.67
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Central Health Plan Commercial |
$31.47
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$53.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$35.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$35.67
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.41
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$29.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$58.50
|
| Rate for Payer: IEHP medi-cal |
$58.86
|
| Rate for Payer: IEHP Medicare Advantage |
$35.67
|
| Rate for Payer: Innovage PACE Commercial |
$53.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.80
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
| Rate for Payer: Prime Health Services Medicare |
$37.81
|
| Rate for Payer: Riverside University Health MISP |
$39.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.67
|
| Rate for Payer: United Healthcare All Other HMO |
$19.67
|
| Rate for Payer: United Healthcare HMO Rider |
$19.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$53.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.24
|
| Rate for Payer: Vantage Medical Group Senior |
$35.67
|
|
|
DAUNORUBICIN 5 MG/ML INTRAVENOUS SOLUTION [22661]
|
Facility
IP
|
$39.34
|
|
|
Service Code
|
CPT J9150
|
| Hospital Charge Code |
1755125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Blue Shield of California Commercial |
$29.50
|
| Rate for Payer: Blue Shield of California EPN |
$21.01
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Central Health Plan Commercial |
$31.47
|
| Rate for Payer: Cigna of CA HMO |
$27.54
|
| Rate for Payer: Cigna of CA PPO |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.74
|
| Rate for Payer: Galaxy Health WC |
$33.44
|
| Rate for Payer: Global Benefits Group Commercial |
$23.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$35.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.87
|
| Rate for Payer: Multiplan Commercial |
$29.50
|
| Rate for Payer: Networks By Design Commercial |
$19.67
|
| Rate for Payer: Prime Health Services Commercial |
$33.44
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 11047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
|
Facility
OP
|
$6,248.00
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$6,248.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,025.69
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,025.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,734.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,025.69
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,322.13
|
| Rate for Payer: IEHP medi-cal |
$3,342.39
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Innovage PACE Commercial |
$3,038.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,025.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,714.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,714.42
|
| Rate for Payer: Prime Health Services Medicare |
$2,147.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: Riverside University Health MISP |
$2,228.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 11010
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$879.07 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$879.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$879.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,186.74
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$879.07
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,441.67
|
| Rate for Payer: IEHP medi-cal |
$1,450.47
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Innovage PACE Commercial |
$1,318.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$879.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,177.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,177.95
|
| Rate for Payer: Prime Health Services Medicare |
$931.81
|
| Rate for Payer: Riverside University Health MISP |
$966.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle
|
Facility
OP
|
$6,248.00
|
|
|
Service Code
|
CPT 11011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$879.07 |
| Max. Negotiated Rate |
$6,248.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$879.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$879.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,186.74
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$879.07
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,441.67
|
| Rate for Payer: IEHP medi-cal |
$1,450.47
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Innovage PACE Commercial |
$1,318.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$879.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,177.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,177.95
|
| Rate for Payer: Prime Health Services Medicare |
$931.81
|
| Rate for Payer: Riverside University Health MISP |
$966.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
|
Facility
OP
|
$6,248.00
|
|
|
Service Code
|
CPT 11012
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,257.00 |
| Max. Negotiated Rate |
$6,248.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,550.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$3,550.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,792.85
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,550.26
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$5,822.43
|
| Rate for Payer: IEHP medi-cal |
$5,857.93
|
| Rate for Payer: IEHP Medicare Advantage |
$3,550.26
|
| Rate for Payer: Innovage PACE Commercial |
$5,325.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,550.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,757.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,757.35
|
| Rate for Payer: Prime Health Services Medicare |
$3,763.28
|
| Rate for Payer: Riverside University Health MISP |
$3,905.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
|
Facility
OP
|
$6,248.00
|
|
|
Service Code
|
CPT 11043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$6,248.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$784.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$784.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,059.36
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$784.71
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,286.92
|
| Rate for Payer: IEHP medi-cal |
$1,294.77
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Innovage PACE Commercial |
$1,177.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$784.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,051.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,051.51
|
| Rate for Payer: Prime Health Services Medicare |
$831.79
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: Riverside University Health MISP |
$863.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
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
|
$397,400.00
|
|
|
Service Code
|
CPT 11045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
|
Facility
OP
|
$6,248.00
|
|
|
Service Code
|
CPT 11042
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$6,248.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$498.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$498.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$672.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$817.05
|
| Rate for Payer: IEHP medi-cal |
$822.03
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Innovage PACE Commercial |
$747.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$498.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$667.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$667.59
|
| Rate for Payer: Prime Health Services Medicare |
$528.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$225.00
|
| Rate for Payer: Riverside University Health MISP |
$548.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
IP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$388.79 |
| Max. Negotiated Rate |
$1,749.56 |
| Rate for Payer: Blue Shield of California Commercial |
$1,457.96
|
| Rate for Payer: Blue Shield of California EPN |
$1,038.07
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Central Health Plan Commercial |
$1,555.16
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,749.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$388.79
|
| Rate for Payer: Multiplan Commercial |
$1,457.96
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
OP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$388.79 |
| Max. Negotiated Rate |
$1,749.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1,180.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,069.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,069.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$941.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,148.49
|
| Rate for Payer: BCBS Transplant Transplant |
$1,166.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1,222.74
|
| Rate for Payer: Blue Shield of California EPN |
$950.59
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Central Health Plan Commercial |
$1,555.16
|
| Rate for Payer: Cigna of CA HMO |
$1,360.76
|
| Rate for Payer: Cigna of CA PPO |
$1,360.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,652.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$777.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$777.58
|
| Rate for Payer: Galaxy Health WC |
$1,652.36
|
| Rate for Payer: Global Benefits Group Commercial |
$1,166.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,749.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,457.96
|
| Rate for Payer: IEHP medi-cal |
$680.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,296.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$388.79
|
| Rate for Payer: Multiplan Commercial |
$1,457.96
|
| Rate for Payer: Networks By Design Commercial |
$1,263.57
|
| Rate for Payer: Prime Health Services Commercial |
$1,652.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1,166.37
|
| Rate for Payer: Riverside University Health MISP |
$777.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,166.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,166.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$971.98
|
| Rate for Payer: United Healthcare All Other HMO |
$971.98
|
| Rate for Payer: United Healthcare HMO Rider |
$971.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$971.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1,652.36
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$396.00
|
| 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 Exchange |
$49.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.21
|
| Rate for Payer: BCBS Transplant Transplant |
$432.00
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| Rate for Payer: BCBS Transplant Transplant |
$142.56
|
| Rate for Payer: BCBS Transplant Transplant |
$72.00
|
| Rate for Payer: Blue Shield of California Commercial |
$17.16
|
| Rate for Payer: Blue Shield of California Commercial |
$17.16
|
| Rate for Payer: Blue Shield of California Commercial |
$17.16
|
| Rate for Payer: Blue Shield of California Commercial |
$17.16
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Blue Shield of California EPN |
$15.60
|
| Rate for Payer: Cash Price |
$108.00
|
| 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 |
$108.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| 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 |
$576.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| 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 |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$648.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$213.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$180.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$540.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$178.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.00
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: IEHP medi-cal |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Riverside University Health MISP |
$96.00
|
| Rate for Payer: Riverside University Health MISP |
$95.04
|
| Rate for Payer: Riverside University Health MISP |
$48.00
|
| Rate for Payer: Riverside University Health MISP |
$288.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$432.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$432.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$118.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO |
$118.80
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$118.80
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$360.00
|
| Rate for Payer: United Healthcare HMO Rider |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$118.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$360.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
|
