|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
CPT J0153
|
| Hospital Charge Code |
1720684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.48
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
CPT J0153
|
| Hospital Charge Code |
1720684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$7.89 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: IEHP Medi-Cal |
$7.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
IP
|
$5.11
|
|
|
Service Code
|
CPT J0153
|
| Hospital Charge Code |
1720905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.33
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.46
|
| Rate for Payer: Heritage Provider Network Senior |
$3.09
|
| Rate for Payer: Heritage Provider Network Senior |
$3.87
|
| Rate for Payer: Heritage Provider Network Senior |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
OP
|
$7.76
|
|
|
Service Code
|
CPT J0153
|
| Hospital Charge Code |
1720905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$7.89 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Senior |
$3.88
|
| Rate for Payer: Dignity Health Senior |
$4.34
|
| Rate for Payer: Dignity Health Senior |
$6.60
|
| Rate for Payer: Dignity Health Senior |
$4.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$2.37
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$2.12
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: IEHP Medi-Cal |
$7.89
|
| Rate for Payer: IEHP Medi-Cal |
$7.89
|
| Rate for Payer: IEHP Medi-Cal |
$7.89
|
| Rate for Payer: IEHP Medi-Cal |
$7.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$3.43
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$4.34
|
| Rate for Payer: Vantage Medical Group Senior |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$3.88
|
|
|
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14301
|
| Min. Negotiated Rate |
$277.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medi-Cal |
$277.04
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14302
|
| Min. Negotiated Rate |
$295.62 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$295.62
|
|
|
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14061
|
| Min. Negotiated Rate |
$1,155.77 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$1,155.77
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14060
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$131.84
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14041
|
| Min. Negotiated Rate |
$658.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$658.04
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14040
|
| Min. Negotiated Rate |
$105.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$105.13
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14021
|
| Min. Negotiated Rate |
$526.19 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$526.19
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14020
|
| Min. Negotiated Rate |
$78.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$78.98
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14001
|
| Min. Negotiated Rate |
$455.33 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$455.33
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14000
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$69.70
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| 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
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$10,265.34
|
|
|
Service Code
|
APR-DRG 7554
|
| Min. Negotiated Rate |
$10,265.34 |
| Max. Negotiated Rate |
$10,265.34 |
| Rate for Payer: IEHP Medi-Cal |
$10,265.34
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$3,798.51
|
|
|
Service Code
|
APR-DRG 7552
|
| Min. Negotiated Rate |
$3,798.51 |
| Max. Negotiated Rate |
$3,798.51 |
| Rate for Payer: IEHP Medi-Cal |
$3,798.51
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$5,954.45
|
|
|
Service Code
|
APR-DRG 7553
|
| Min. Negotiated Rate |
$5,954.45 |
| Max. Negotiated Rate |
$5,954.45 |
| Rate for Payer: IEHP Medi-Cal |
$5,954.45
|
|
|
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
|
Facility
IP
|
$2,590.70
|
|
|
Service Code
|
APR-DRG 7551
|
| Min. Negotiated Rate |
$2,590.70 |
| Max. Negotiated Rate |
$2,590.70 |
| Rate for Payer: IEHP Medi-Cal |
$2,590.70
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
IP
|
$4,490.48
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$812.78 |
| Max. Negotiated Rate |
$3,367.86 |
| Rate for Payer: Adventist Health Commercial |
$898.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,084.96
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,065.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,424.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,040.05
|
| Rate for Payer: Heritage Provider Network Senior |
$3,040.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$812.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,122.62
|
| Rate for Payer: Multiplan Commercial |
$3,367.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,637.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,500.27
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
OP
|
$4,490.48
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$3,367.86 |
| Rate for Payer: Adventist Health Commercial |
$898.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,084.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.28
|
| Rate for Payer: Blue Shield of California Commercial |
$35.84
|
| Rate for Payer: Blue Shield of California EPN |
$35.84
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cash Price |
$2,020.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,065.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.20
|
| Rate for Payer: Dignity Health Senior |
$42.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,873.91
|
| Rate for Payer: EPIC Health Plan Medicare |
$38.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,079.09
|
| Rate for Payer: Heritage Provider Network Senior |
$2,079.09
|
| Rate for Payer: Humana Medicare |
$38.37
|
| Rate for Payer: IEHP Medi-Cal |
$66.81
|
| Rate for Payer: IEHP Medicare Advantage |
$38.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$812.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$45.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,122.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.34
|
| Rate for Payer: Multiplan Commercial |
$3,367.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.20
|
| Rate for Payer: TriValley Medical Group Senior |
$38.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,637.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,500.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Vantage Medical Group Senior |
$38.37
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
IP
|
$7,184.76
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,300.44 |
| Max. Negotiated Rate |
$5,388.57 |
| Rate for Payer: Adventist Health Commercial |
$1,436.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,935.93
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,304.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,879.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,864.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4,864.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.19
|
| Rate for Payer: Multiplan Commercial |
$5,388.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,619.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,400.43
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
OP
|
$7,184.76
|
|
|
Service Code
|
CPT J9354
|
| Hospital Charge Code |
ERX200178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$5,388.57 |
| Rate for Payer: Adventist Health Commercial |
$1,436.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$75.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,935.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.28
|
| Rate for Payer: Blue Shield of California Commercial |
$35.84
|
| Rate for Payer: Blue Shield of California EPN |
$35.84
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cash Price |
$3,233.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,304.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.20
|
| Rate for Payer: Dignity Health Senior |
$42.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,598.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$38.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,326.54
|
| Rate for Payer: Heritage Provider Network Senior |
$3,326.54
|
| Rate for Payer: Humana Medicare |
$38.37
|
| Rate for Payer: IEHP Medi-Cal |
$66.81
|
| Rate for Payer: IEHP Medicare Advantage |
$38.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$72.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,300.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$45.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.34
|
| Rate for Payer: Multiplan Commercial |
$5,388.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.20
|
| Rate for Payer: TriValley Medical Group Senior |
$38.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,619.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,400.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.20
|
| Rate for Payer: Vantage Medical Group Senior |
$38.37
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$20,274.98
|
|
|
Service Code
|
APR-DRG 4012
|
| Min. Negotiated Rate |
$20,274.98 |
| Max. Negotiated Rate |
$20,274.98 |
| Rate for Payer: IEHP Medi-Cal |
$20,274.98
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$25,443.47
|
|
|
Service Code
|
APR-DRG 4013
|
| Min. Negotiated Rate |
$25,443.47 |
| Max. Negotiated Rate |
$25,443.47 |
| Rate for Payer: IEHP Medi-Cal |
$25,443.47
|
|
|
ADRENAL PROCEDURES
|
Facility
IP
|
$11,505.97
|
|
|
Service Code
|
APR-DRG 4011
|
| Min. Negotiated Rate |
$11,505.97 |
| Max. Negotiated Rate |
$11,505.97 |
| Rate for Payer: IEHP Medi-Cal |
$11,505.97
|
|
