|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
GLYCOPYRROLATE 1 MG TABLET [10130]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16571-743-09
|
| Hospital Charge Code |
1710675
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 49884-066-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Distinction Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.05
|
| Rate for Payer: Blue Distinction Transplant |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Central Health Plan Commercial |
$1.42
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.51
|
| Rate for Payer: Dignity Health Media |
$1.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
| Rate for Payer: Riverside University Health System MISP |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Other HMO |
$0.89
|
| Rate for Payer: United Healthcare HMO Rider |
$0.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.51
|
| Rate for Payer: Vantage Medical Group Senior |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
NDC 55111-649-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Blue Shield of California Commercial |
$1.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Central Health Plan Commercial |
$1.42
|
| Rate for Payer: Cigna of CA HMO |
$1.25
|
| Rate for Payer: Cigna of CA PPO |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Galaxy Health WC |
$1.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.34
|
| Rate for Payer: Networks By Design Commercial |
$1.16
|
| Rate for Payer: Prime Health Services Commercial |
$1.51
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
GLYCOPYRROLATE 2 MG TABLET [10131]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 64980-273-01
|
| Hospital Charge Code |
1710681
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Distinction Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.74
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.84
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Blue Shield of California Commercial |
$1.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Central Health Plan Commercial |
$2.10
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
|
|
GLYCOPYRROLATE ORAL SOLUTION (IV FORM) 0.2 MG/ML [4080432]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 9994-0804-32
|
| Hospital Charge Code |
1715584
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.55
|
| Rate for Payer: Blue Distinction Transplant |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.65
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Central Health Plan Commercial |
$2.10
|
| Rate for Payer: Cigna of CA HMO |
$1.84
|
| Rate for Payer: Cigna of CA PPO |
$1.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.24
|
| Rate for Payer: Dignity Health Media |
$2.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.05
|
| Rate for Payer: Galaxy Health WC |
$2.24
|
| Rate for Payer: Global Benefits Group Commercial |
$1.58
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.97
|
| Rate for Payer: Networks By Design Commercial |
$1.71
|
| Rate for Payer: Prime Health Services Commercial |
$2.24
|
| Rate for Payer: Riverside University Health System MISP |
$1.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO |
$1.32
|
| Rate for Payer: United Healthcare HMO Rider |
$1.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.24
|
| Rate for Payer: Vantage Medical Group Senior |
$2.24
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
IP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.95 |
| Max. Negotiated Rate |
$539.78 |
| Rate for Payer: Blue Shield of California Commercial |
$449.82
|
| Rate for Payer: Blue Shield of California EPN |
$320.27
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Central Health Plan Commercial |
$479.81
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$539.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.95
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$226.47
|
| Rate for Payer: United Healthcare All Other HMO |
$221.19
|
| Rate for Payer: United Healthcare HMO Rider |
$216.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$197.92
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [203118]
|
Facility
|
OP
|
$599.76
|
|
|
Service Code
|
NDC 57894-350-01
|
| Hospital Charge Code |
NDG203118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.95 |
| Max. Negotiated Rate |
$539.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$364.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$509.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$329.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$329.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$290.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.34
|
| Rate for Payer: Blue Distinction Transplant |
$359.86
|
| Rate for Payer: Blue Shield of California Commercial |
$377.25
|
| Rate for Payer: Blue Shield of California EPN |
$293.28
|
| Rate for Payer: Cash Price |
$269.89
|
| Rate for Payer: Central Health Plan Commercial |
$479.81
|
| Rate for Payer: Cigna of CA HMO |
$419.83
|
| Rate for Payer: Cigna of CA PPO |
$419.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$509.80
|
| Rate for Payer: Dignity Health Media |
$509.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$239.90
|
| Rate for Payer: Galaxy Health WC |
$509.80
|
| Rate for Payer: Global Benefits Group Commercial |
$359.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$539.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$449.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$209.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.95
|
| Rate for Payer: Multiplan Commercial |
$449.82
|
| Rate for Payer: Networks By Design Commercial |
$299.88
|
| Rate for Payer: Prime Health Services Commercial |
$509.80
|
| Rate for Payer: Riverside University Health System MISP |
$239.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$359.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$359.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$299.88
|
| Rate for Payer: United Healthcare All Other HMO |
$299.88
|
| Rate for Payer: United Healthcare HMO Rider |
$299.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$299.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.80
|
| Rate for Payer: Vantage Medical Group Senior |
$509.80
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$166.20 |
| Max. Negotiated Rate |
$977.79 |
| Rate for Payer: Adventist Health Medi-Cal |
$166.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$977.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$182.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$316.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$346.71
|
| Rate for Payer: Blue Distinction Transplant |
$576.00
|
| Rate for Payer: Blue Shield of California Commercial |
$211.20
|
| Rate for Payer: Blue Shield of California EPN |
$192.00
|
| Rate for Payer: Caremore Medicare Advantage |
$166.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$207.75
|
| Rate for Payer: Dignity Health Media |
$182.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.37
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$166.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$166.20
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$720.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$272.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$274.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$166.20
|
| Rate for Payer: InnovAge PACE Commercial |
$249.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$222.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$222.71
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Prime Health Services Medicare |
$176.17
|
| Rate for Payer: Riverside University Health System MISP |
$182.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Other HMO |
$480.00
|
| Rate for Payer: United Healthcare HMO Rider |
$480.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$480.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$207.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.82
|
| Rate for Payer: Vantage Medical Group Senior |
$182.82
|
|
|
GOLODIRSEN 50 MG/ML INTRAVENOUS SOLUTION [226694]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
CPT J1429
|
| Hospital Charge Code |
NDG226694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Blue Shield of California Commercial |
$720.00
|
| Rate for Payer: Blue Shield of California EPN |
$512.64
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$365.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$362.50
|
| Rate for Payer: United Healthcare All Other HMO |
$354.05
|
| Rate for Payer: United Healthcare HMO Rider |
$346.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$316.80
|
|
|
Goniotomy
|
Facility
|
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$160.57 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| 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 |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Dignity Health Media |
$5,080.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,588.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8,382.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,080.00
|
| Rate for Payer: InnovAge PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$160.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health System MISP |
$5,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
OP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$579.49 |
| Max. Negotiated Rate |
$2,607.72 |
| Rate for Payer: Adventist Health Medi-Cal |
$609.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,199.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$861.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$943.11
|
| Rate for Payer: Blue Distinction Transplant |
$1,738.48
|
| Rate for Payer: Blue Shield of California Commercial |
$921.55
|
| Rate for Payer: Blue Shield of California EPN |
$837.77
|
| Rate for Payer: Caremore Medicare Advantage |
$609.01
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Central Health Plan Commercial |
$2,317.98
|
| Rate for Payer: Cigna of CA HMO |
$2,028.23
|
| Rate for Payer: Cigna of CA PPO |
$2,028.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Media |
$609.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$609.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$609.01
|
| Rate for Payer: Galaxy Health WC |
$2,462.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,738.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,607.72
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,173.10
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$998.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,004.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$609.01
|
| Rate for Payer: InnovAge PACE Commercial |
$913.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,932.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$609.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$579.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$816.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$816.07
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: Networks By Design Commercial |
$1,448.74
|
| Rate for Payer: Prime Health Services Commercial |
$2,462.85
|
| Rate for Payer: Prime Health Services Medicare |
$645.55
|
| Rate for Payer: Riverside University Health System MISP |
$669.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,738.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,738.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,448.74
|
| Rate for Payer: United Healthcare All Other HMO |
$1,448.74
|
| Rate for Payer: United Healthcare HMO Rider |
$1,448.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,448.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT [16254]
|
Facility
|
IP
|
$2,897.47
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$579.49 |
| Max. Negotiated Rate |
$2,607.72 |
| Rate for Payer: Blue Shield of California Commercial |
$2,173.10
|
| Rate for Payer: Blue Shield of California EPN |
$1,547.25
|
| Rate for Payer: Cash Price |
$1,303.86
|
| Rate for Payer: Central Health Plan Commercial |
$2,317.98
|
| Rate for Payer: Cigna of CA HMO |
$2,028.23
|
| Rate for Payer: Cigna of CA PPO |
$2,028.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,158.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,158.99
|
| Rate for Payer: Galaxy Health WC |
$2,462.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,738.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$2,607.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,932.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,103.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$579.49
|
| Rate for Payer: Multiplan Commercial |
$2,173.10
|
| Rate for Payer: Networks By Design Commercial |
$1,448.74
|
| Rate for Payer: Prime Health Services Commercial |
$2,462.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,094.08
|
| Rate for Payer: United Healthcare All Other HMO |
$1,068.59
|
| Rate for Payer: United Healthcare HMO Rider |
$1,045.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$956.17
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
IP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.69 |
| Max. Negotiated Rate |
$930.09 |
| Rate for Payer: Blue Shield of California Commercial |
$775.07
|
| Rate for Payer: Blue Shield of California EPN |
$551.85
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Central Health Plan Commercial |
$826.74
|
| Rate for Payer: Cigna of CA HMO |
$723.40
|
| Rate for Payer: Cigna of CA PPO |
$723.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$413.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$413.37
|
| Rate for Payer: Galaxy Health WC |
$878.42
|
| Rate for Payer: Global Benefits Group Commercial |
$620.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$930.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$689.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$393.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.69
|
| Rate for Payer: Multiplan Commercial |
$775.07
|
| Rate for Payer: Networks By Design Commercial |
$516.72
|
| Rate for Payer: Prime Health Services Commercial |
$878.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$390.22
|
| Rate for Payer: United Healthcare All Other HMO |
$381.13
|
| Rate for Payer: United Healthcare HMO Rider |
$372.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$341.03
|
|
|
GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT [10137]
|
Facility
|
OP
|
$1,033.43
|
|
|
Service Code
|
CPT J9202
|
| Hospital Charge Code |
1755721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.69 |
| Max. Negotiated Rate |
$1,199.44 |
| Rate for Payer: Adventist Health Medi-Cal |
$609.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,199.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$761.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$669.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$861.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$943.11
|
| Rate for Payer: Blue Distinction Transplant |
$620.06
|
| Rate for Payer: Blue Shield of California Commercial |
$921.55
|
| Rate for Payer: Blue Shield of California EPN |
$837.77
|
| Rate for Payer: Caremore Medicare Advantage |
$609.01
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Cash Price |
$465.04
|
| Rate for Payer: Central Health Plan Commercial |
$826.74
|
| Rate for Payer: Cigna of CA HMO |
$723.40
|
| Rate for Payer: Cigna of CA PPO |
$723.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$913.51
|
| Rate for Payer: Dignity Health Media |
$609.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$669.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.16
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$609.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$609.01
|
| Rate for Payer: Galaxy Health WC |
$878.42
|
| Rate for Payer: Global Benefits Group Commercial |
$620.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$930.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$775.07
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$998.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1,004.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$609.01
|
| Rate for Payer: InnovAge PACE Commercial |
$913.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$689.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,157.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$609.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$206.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$816.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$816.07
|
| Rate for Payer: Multiplan Commercial |
$775.07
|
| Rate for Payer: Networks By Design Commercial |
$516.72
|
| Rate for Payer: Prime Health Services Commercial |
$878.42
|
| Rate for Payer: Prime Health Services Medicare |
$645.55
|
| Rate for Payer: Riverside University Health System MISP |
$669.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$620.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$620.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$516.72
|
| Rate for Payer: United Healthcare All Other HMO |
$516.72
|
| Rate for Payer: United Healthcare HMO Rider |
$516.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$516.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$913.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$669.91
|
| Rate for Payer: Vantage Medical Group Senior |
$609.01
|
|
|
Graft, bone; mandible (includes obtaining graft)
|
Facility
|
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 21215
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$282.95 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,072.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: InnovAge PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$282.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health System MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area
|
Facility
|
OP
|
$7,027.00
|
|
|
Service Code
|
CPT 15760
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$801.46 |
| Max. Negotiated Rate |
$7,027.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3,759.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: InnovAge PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$801.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health System MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Graft; derma-fat-fascia
|
Facility
|
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 15770
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$848.84 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,482.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,482.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Media |
$4,482.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,351.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,396.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: InnovAge PACE Commercial |
$6,723.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$848.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,006.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,751.45
|
| Rate for Payer: Riverside University Health System MISP |
$4,930.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
|
Facility
|
OP
|
$12,072.88
|
|
|
Service Code
|
CPT 21235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.41 |
| Max. Negotiated Rate |
$12,072.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,072.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: InnovAge PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$192.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health System MISP |
$8,048.59
|
| 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 |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
|
Facility
|
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 15840
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,122.11 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,482.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10,567.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| 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 |
$5,824.53
|
| Rate for Payer: Blue Shield of California EPN |
$4,183.44
|
| Rate for Payer: Caremore Medicare Advantage |
$4,482.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Media |
$4,482.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,351.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$7,396.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,482.50
|
| Rate for Payer: InnovAge PACE Commercial |
$6,723.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,122.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,006.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,751.45
|
| Rate for Payer: Riverside University Health System MISP |
$4,930.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
|
Facility
|
OP
|
$7,084.00
|
|
|
Service Code
|
CPT 15773
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$985.53 |
| Max. Negotiated Rate |
$7,084.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Media |
$2,278.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3,759.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,278.49
|
| Rate for Payer: InnovAge PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$985.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health System MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
