|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
IP
|
$120.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$90.00
|
| Rate for Payer: Blue Shield of California Commercial |
$540.00
|
| Rate for Payer: Blue Shield of California Commercial |
$178.20
|
| Rate for Payer: Blue Shield of California Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California EPN |
$64.08
|
| Rate for Payer: Blue Shield of California EPN |
$126.88
|
| Rate for Payer: Blue Shield of California EPN |
$128.16
|
| Rate for Payer: Blue Shield of California EPN |
$384.48
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Central Health Plan Commercial |
$96.00
|
| Rate for Payer: Central Health Plan Commercial |
$190.08
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Central Health Plan Commercial |
$576.00
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| 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 |
$288.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: 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 |
$432.00
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$213.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$648.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$158.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$480.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| 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 |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Prime Health Services Commercial |
$102.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
OP
|
$720.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$648.00 |
| 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 |
$612.00
|
| 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 |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.68
|
| 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 |
$142.56
|
| Rate for Payer: BCBS Transplant Transplant |
$72.00
|
| Rate for Payer: BCBS Transplant Transplant |
$144.00
|
| 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 |
$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 |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: 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: Central Health Plan Commercial |
$190.08
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$166.32
|
| Rate for Payer: Cigna of CA HMO |
$84.00
|
| Rate for Payer: Cigna of CA HMO |
$504.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$166.32
|
| Rate for Payer: Cigna of CA PPO |
$84.00
|
| Rate for Payer: Cigna of CA PPO |
$504.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$288.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$288.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.00
|
| Rate for Payer: Galaxy Health WC |
$612.00
|
| Rate for Payer: Galaxy Health WC |
$201.96
|
| Rate for Payer: Galaxy Health WC |
$102.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$142.56
|
| Rate for Payer: Global Benefits Group Commercial |
$72.00
|
| Rate for Payer: Global Benefits Group Commercial |
$432.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$108.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$213.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$648.00
|
| 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 |
$90.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$178.20
|
| 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 |
$480.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.04
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$48.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$118.80
|
| Rate for Payer: Networks By Design Commercial |
$60.00
|
| Rate for Payer: Networks By Design Commercial |
$360.00
|
| Rate for Payer: Prime Health Services Commercial |
$201.96
|
| Rate for Payer: Prime Health Services Commercial |
$612.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| 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 |
$432.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$142.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$142.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$432.00
|
| 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 |
$60.00
|
| 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 |
$60.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| 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 |
$60.00
|
| Rate for Payer: United Healthcare HMO Rider |
$360.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$360.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$118.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
|
|
Decompressive fasciotomy, hand (excludes 26035)
|
Facility
OP
|
$10,567.00
|
|
|
Service Code
|
CPT 26037
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$10,567.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,044.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| 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 |
$4,044.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,459.68
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,044.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,632.50
|
| Rate for Payer: IEHP medi-cal |
$6,672.95
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Innovage PACE Commercial |
$6,066.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,044.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,419.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,419.24
|
| Rate for Payer: Prime Health Services Medicare |
$4,286.86
|
| Rate for Payer: Riverside University Health MISP |
$4,448.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 294
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 295
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$87.71
|
| Rate for Payer: Blue Shield of California EPN |
$62.45
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Central Health Plan Commercial |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.39
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$71.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.09
|
| Rate for Payer: BCBS Transplant Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$73.56
|
| Rate for Payer: Blue Shield of California EPN |
$57.19
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Central Health Plan Commercial |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$87.71
|
| Rate for Payer: IEHP medi-cal |
$40.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.39
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: Riverside University Health MISP |
$46.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$87.71
|
| Rate for Payer: Blue Shield of California EPN |
$62.45
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Central Health Plan Commercial |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.39
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$71.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$56.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.09
|
| Rate for Payer: BCBS Transplant Transplant |
$70.17
|
| Rate for Payer: Blue Shield of California Commercial |
$73.56
|
| Rate for Payer: Blue Shield of California EPN |
$57.19
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Central Health Plan Commercial |
$93.56
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.41
|
| Rate for Payer: Global Benefits Group Commercial |
$70.17
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.26
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$87.71
|
| Rate for Payer: IEHP medi-cal |
$40.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.39
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Networks By Design Commercial |
$76.02
|
| Rate for Payer: Prime Health Services Commercial |
$99.41
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: Riverside University Health MISP |
$46.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.48
|
| Rate for Payer: United Healthcare All Other HMO |
$58.48
|
| Rate for Payer: United Healthcare HMO Rider |
$58.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.02 |
| Max. Negotiated Rate |
$54.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$36.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.50
|
| Rate for Payer: BCBS Transplant Transplant |
$36.05
|
| Rate for Payer: Blue Shield of California Commercial |
$37.79
|
| Rate for Payer: Blue Shield of California EPN |
$29.38
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Central Health Plan Commercial |
$48.06
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.06
|
| Rate for Payer: IEHP medi-cal |
$21.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.02
|
| Rate for Payer: Multiplan Commercial |
$45.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$36.05
|
| Rate for Payer: Riverside University Health MISP |
$24.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.04
|
| Rate for Payer: United Healthcare All Other HMO |
$30.04
|
| Rate for Payer: United Healthcare HMO Rider |
$30.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.07
|
| Rate for Payer: Vantage Medical Group Senior |
$51.07
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.02 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$45.06
|
| Rate for Payer: Blue Shield of California EPN |
$32.08
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Central Health Plan Commercial |
$48.06
|
| Rate for Payer: Cigna of CA HMO |
$42.06
|
| Rate for Payer: Cigna of CA PPO |
$42.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.03
|
| Rate for Payer: Galaxy Health WC |
$51.07
|
| Rate for Payer: Global Benefits Group Commercial |
$36.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.02
|
| Rate for Payer: Multiplan Commercial |
$45.06
|
| Rate for Payer: Networks By Design Commercial |
$39.05
|
| Rate for Payer: Prime Health Services Commercial |
$51.07
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
OP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$210.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$142.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$128.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$128.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$113.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.18
|
| Rate for Payer: BCBS Transplant Transplant |
$140.33
|
| Rate for Payer: Blue Shield of California Commercial |
$147.12
|
| Rate for Payer: Blue Shield of California EPN |
$114.37
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Central Health Plan Commercial |
$187.11
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$198.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$210.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$175.42
|
| Rate for Payer: IEHP medi-cal |
$81.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.78
|
| Rate for Payer: Multiplan Commercial |
$175.42
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$140.33
|
| Rate for Payer: Riverside University Health MISP |
$93.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$140.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$140.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.94
|
| Rate for Payer: United Healthcare All Other HMO |
$116.94
|
| Rate for Payer: United Healthcare HMO Rider |
$116.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$198.81
|
| Rate for Payer: Vantage Medical Group Senior |
$198.81
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
IP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$175.42
|
| Rate for Payer: Blue Shield of California EPN |
$124.90
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Central Health Plan Commercial |
$187.11
|
| Rate for Payer: Cigna of CA HMO |
$163.72
|
| Rate for Payer: Cigna of CA PPO |
$163.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.56
|
| Rate for Payer: Galaxy Health WC |
$198.81
|
| Rate for Payer: Global Benefits Group Commercial |
$140.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$210.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.78
|
| Rate for Payer: Multiplan Commercial |
$175.42
|
| Rate for Payer: Networks By Design Commercial |
$152.03
|
| Rate for Payer: Prime Health Services Commercial |
$198.81
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
IP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$37.08
|
| Rate for Payer: Blue Shield of California EPN |
$26.40
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Central Health Plan Commercial |
$39.55
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.89
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
OP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$53.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$53.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$27.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$26.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.35
|
| Rate for Payer: BCBS Transplant Transplant |
$29.66
|
| Rate for Payer: Blue Shield of California Commercial |
$14.45
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Central Health Plan Commercial |
$39.55
|
| Rate for Payer: Cigna of CA HMO |
$34.61
|
| Rate for Payer: Cigna of CA PPO |
$34.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$19.78
|
| Rate for Payer: Galaxy Health WC |
$42.02
|
| Rate for Payer: Global Benefits Group Commercial |
$29.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$44.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$37.08
|
| Rate for Payer: IEHP medi-cal |
$6.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$32.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.89
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: Networks By Design Commercial |
$24.72
|
| Rate for Payer: Prime Health Services Commercial |
$42.02
|
| Rate for Payer: Riverside University Health MISP |
$19.78
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$29.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$29.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$24.72
|
| Rate for Payer: United Healthcare All Other HMO |
$24.72
|
| Rate for Payer: United Healthcare HMO Rider |
$24.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$11.66
|
| Rate for Payer: Blue Shield of California EPN |
$8.30
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Central Health Plan Commercial |
$12.43
|
| Rate for Payer: Cigna of CA HMO |
$10.88
|
| Rate for Payer: Cigna of CA PPO |
$10.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.22
|
| Rate for Payer: Galaxy Health WC |
$13.21
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$11.66
|
| Rate for Payer: Networks By Design Commercial |
$7.77
|
| Rate for Payer: Prime Health Services Commercial |
$13.21
|
|
