|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
NDC 7857300081
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.84
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 3877929822
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Senior |
$1.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Senior |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
MANGO FLAVOR LIQUID [213757]
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
NDC 7857300081
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Senior |
$1.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.14
|
| Rate for Payer: TriValley Medical Group Senior |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS J2151
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MANNITOL 20 % INTRAVENOUS SOLUTION [4749]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS J2151
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
|
|
MANNITOL 25 % INTRAVENOUS SOLUTION [4750]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
HCPCS J2151
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
|
|
MANNITOL 25 % INTRAVENOUS SOLUTION [4750]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
HCPCS J2151
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), DEEP (EG, SUBFASCIAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
MASTECTOMY FOR MALIGNANCY WITH CC/MCC
|
Facility
|
IP
|
$30,285.43
|
|
|
Service Code
|
MSDRG 582
|
| Min. Negotiated Rate |
$22,601.07 |
| Max. Negotiated Rate |
$30,285.43 |
| Rate for Payer: EPIC Health Plan Medicare |
$22,601.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,601.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25,991.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,285.43
|
|
|
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$27,180.56
|
|
|
Service Code
|
MSDRG 583
|
| Min. Negotiated Rate |
$20,284.00 |
| Max. Negotiated Rate |
$27,180.56 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,284.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,284.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,326.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,180.56
|
|
|
MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE
|
Facility
|
OP
|
$16,226.70
|
|
|
Service Code
|
CPT 19307
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,178.49 |
| Max. Negotiated Rate |
$16,226.70 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,136.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,540.37
|
| Rate for Payer: Heritage Provider Network Senior |
$10,504.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16,226.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,821.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,394.41
|
| Rate for Payer: TriValley Medical Group Senior |
$9,394.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,150.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,259.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
|
MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 19301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,035.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,553.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,539.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,035.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,553.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,539.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,035.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,035.90
|
| Rate for Payer: Heritage Provider Network Senior |
$6,194.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,035.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9,568.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,791.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,748.11
|
| Rate for Payer: Multiplan WC |
$7,752.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,539.49
|
| Rate for Payer: TriValley Medical Group Senior |
$5,539.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,553.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,539.49
|
| Rate for Payer: Vantage Medical Group Senior |
$5,035.90
|
|
|
MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY
|
Facility
|
OP
|
$16,226.70
|
|
|
Service Code
|
CPT 19302
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,435.00 |
| Max. Negotiated Rate |
$16,226.70 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,435.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,829.24
|
| Rate for Payer: Blue Shield of California EPN |
$8,674.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,540.37
|
| Rate for Payer: Heritage Provider Network Senior |
$10,504.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16,226.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,821.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,394.41
|
| Rate for Payer: TriValley Medical Group Senior |
$9,394.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,150.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,259.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
|
MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 19305
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,984.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,136.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
|
|
MASTECTOMY, SIMPLE, COMPLETE
|
Facility
|
OP
|
$16,226.70
|
|
|
Service Code
|
CPT 19303
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,178.49 |
| Max. Negotiated Rate |
$16,226.70 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,540.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,435.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,394.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8,540.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,540.37
|
| Rate for Payer: Heritage Provider Network Senior |
$10,504.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,540.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16,226.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9,821.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,444.10
|
| Rate for Payer: Multiplan WC |
$13,202.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,394.41
|
| Rate for Payer: TriValley Medical Group Senior |
$9,394.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,810.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,394.41
|
| Rate for Payer: Vantage Medical Group Senior |
$8,540.37
|
|
|
MC MICROCATH PHENOM
|
Facility
|
IP
|
$4,988.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
909000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$902.83 |
| Max. Negotiated Rate |
$3,741.00 |
| Rate for Payer: Adventist Health Commercial |
$997.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,212.27
|
| Rate for Payer: Cash Price |
$2,244.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,376.88
|
| Rate for Payer: Heritage Provider Network Senior |
$3,376.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$902.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,247.00
|
| Rate for Payer: Multiplan Commercial |
$3,741.00
|
|
|
MC MICROCATH PHENOM
|
Facility
|
OP
|
$4,988.00
|
|
|
Service Code
|
CPT C1887
|
| Hospital Charge Code |
909000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$902.83 |
| Max. Negotiated Rate |
$4,239.80 |
| Rate for Payer: Adventist Health Commercial |
$997.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,082.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,239.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,743.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,741.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,495.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,042.68
|
| Rate for Payer: Blue Shield of California EPN |
$2,434.14
|
| Rate for Payer: Cash Price |
$2,244.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,242.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,239.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,239.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,239.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,942.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,087.57
|
| Rate for Payer: Heritage Provider Network Senior |
$3,087.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,379.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$902.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,247.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,491.60
|
| Rate for Payer: Multiplan Commercial |
$3,741.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,494.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,494.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,239.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,239.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4,239.80
|
|
|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
OP
|
$114.89
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$100.33 |
| Rate for Payer: Adventist Health Commercial |
$22.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$71.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$63.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$86.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$100.33
|
| Rate for Payer: Blue Shield of California Commercial |
$93.96
|
| Rate for Payer: Blue Shield of California EPN |
$93.96
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.19
|
| Rate for Payer: Heritage Provider Network Senior |
$53.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.42
|
| Rate for Payer: Multiplan Commercial |
$86.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.96
|
| Rate for Payer: TriValley Medical Group Senior |
$45.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.66
|
| Rate for Payer: Vantage Medical Group Senior |
$97.66
|
|
|
MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [10512]
|
Facility
|
IP
|
$114.89
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$86.17 |
| Rate for Payer: Adventist Health Commercial |
$22.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.99
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$62.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.19
|
| Rate for Payer: Heritage Provider Network Senior |
$53.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.72
|
| Rate for Payer: Multiplan Commercial |
$86.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$41.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.04
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 5026852211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 5026852211
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 5026852215
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 5026852215
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 6068777511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
MECLIZINE 12.5 MG TABLET [12024]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 6068777511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
