|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML INTRAVENOUS PIGGYBACK [248092]
|
Facility
|
OP
|
$27.40
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$23.29 |
| Rate for Payer: Adventist Health Commercial |
$5.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$23.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$12.33
|
| Rate for Payer: Cash Price |
$12.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$23.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.69
|
| Rate for Payer: Heritage Provider Network Senior |
$12.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.18
|
| Rate for Payer: Multiplan Commercial |
$20.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.96
|
| Rate for Payer: TriValley Medical Group Senior |
$10.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.29
|
| Rate for Payer: Vantage Medical Group Senior |
$23.29
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]
|
Facility
|
OP
|
$4.20
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$12.26 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$1.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.94
|
| Rate for Payer: Multiplan Commercial |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.64
|
| Rate for Payer: TriValley Medical Group Senior |
$1.68
|
| Rate for Payer: TriValley Medical Group Senior |
$2.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.61
|
| Rate for Payer: Vantage Medical Group Senior |
$5.61
|
| Rate for Payer: Vantage Medical Group Senior |
$3.57
|
|
|
PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION [18303]
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Adventist Health Commercial |
$0.84
|
| Rate for Payer: Adventist Health Commercial |
$1.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$3.06
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.65
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$4.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.39
|
|
|
PIPERACILLIN-TAZOBACTAM 40.5 GRAM INTRAVENOUS SOLUTION [12587]
|
Facility
|
IP
|
$87.48
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$65.61 |
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Adventist Health Commercial |
$35.22
|
| Rate for Payer: Adventist Health Commercial |
$16.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$113.42
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cash Price |
$79.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$81.54
|
| Rate for Payer: Heritage Provider Network Senior |
$40.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.87
|
| Rate for Payer: Multiplan Commercial |
$65.61
|
| Rate for Payer: Multiplan Commercial |
$132.09
|
| Rate for Payer: Multiplan Commercial |
$62.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
|
|
PIPERACILLIN-TAZOBACTAM 40.5 GRAM INTRAVENOUS SOLUTION [12587]
|
Facility
|
OP
|
$176.12
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$149.70 |
| Rate for Payer: Adventist Health Commercial |
$35.22
|
| Rate for Payer: Adventist Health Commercial |
$16.56
|
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$54.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$108.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$70.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$149.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$48.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$96.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$65.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cash Price |
$79.25
|
| Rate for Payer: Cash Price |
$79.25
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$149.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$149.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$70.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$74.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$149.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.50
|
| Rate for Payer: Heritage Provider Network Senior |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$81.54
|
| Rate for Payer: Heritage Provider Network Senior |
$40.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$41.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$39.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$84.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$123.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$61.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$62.10
|
| Rate for Payer: Multiplan Commercial |
$65.61
|
| Rate for Payer: Multiplan Commercial |
$132.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$33.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$70.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$34.99
|
| Rate for Payer: TriValley Medical Group Senior |
$34.99
|
| Rate for Payer: TriValley Medical Group Senior |
$33.12
|
| Rate for Payer: TriValley Medical Group Senior |
$70.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$70.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$149.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$149.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.38
|
| Rate for Payer: Vantage Medical Group Senior |
$149.70
|
| Rate for Payer: Vantage Medical Group Senior |
$74.36
|
| Rate for Payer: Vantage Medical Group Senior |
$70.38
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML DEXTROSE(ISO-OSM) IV PIGGYBACK [108121]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$12.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML DEXTROSE(ISO-OSM) IV PIGGYBACK [108121]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML INTRAVENOUS PIGGYBACK [247540]
|
Facility
|
IP
|
$33.70
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.10 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Adventist Health Commercial |
$6.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.70
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.60
|
| Rate for Payer: Heritage Provider Network Senior |
$15.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Multiplan Commercial |
$25.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.16
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML INTRAVENOUS PIGGYBACK [247540]
|
Facility
|
OP
|
$33.70
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Adventist Health Commercial |
$6.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$28.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.60
|
| Rate for Payer: Heritage Provider Network Senior |
$15.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.59
|
| Rate for Payer: Multiplan Commercial |
$25.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.48
|
| Rate for Payer: TriValley Medical Group Senior |
$13.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.64
|
| Rate for Payer: Vantage Medical Group Senior |
$28.64
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
OP
|
$7.80
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$12.26 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Adventist Health Commercial |
$1.63
|
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.88
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3.12
|
| Rate for Payer: Heritage Provider Network Senior |
$3.78
|
| Rate for Payer: Heritage Provider Network Senior |
$5.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.71
|
| Rate for Payer: Multiplan Commercial |
$6.12
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.69
|
| Rate for Payer: TriValley Medical Group Senior |
$2.69
|
| Rate for Payer: TriValley Medical Group Senior |
$3.26
|
| Rate for Payer: TriValley Medical Group Senior |
$3.12
|
| Rate for Payer: TriValley Medical Group Senior |
$5.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6.63
|
| Rate for Payer: Vantage Medical Group Senior |
$5.72
|
| Rate for Payer: Vantage Medical Group Senior |
$6.94
|
| Rate for Payer: Vantage Medical Group Senior |
$10.79
|
|
|
PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION [18302]
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Adventist Health Commercial |
$1.56
|
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Adventist Health Commercial |
$1.63
|
| Rate for Payer: Adventist Health Commercial |
$2.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.26
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$3.61
|
| Rate for Payer: Heritage Provider Network Senior |
$5.88
|
| Rate for Payer: Heritage Provider Network Senior |
$3.12
|
| Rate for Payer: Heritage Provider Network Senior |
$3.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$9.53
|
| Rate for Payer: Multiplan Commercial |
$5.85
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$6.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.70
|
|
|
PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR SIMPLE
|
Facility
|
OP
|
$14,466.39
|
|
|
Service Code
|
CPT 42500
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$14,466.39 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11,420.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,613.89
|
| 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 |
$11,420.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,375.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7,613.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,613.89
|
| Rate for Payer: Heritage Provider Network Senior |
$9,365.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,613.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14,466.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,755.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10,202.61
|
| Rate for Payer: Multiplan WC |
$11,976.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,375.28
|
| Rate for Payer: TriValley Medical Group Senior |
$8,375.28
|
| 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 |
$11,420.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,375.28
|
| Rate for Payer: Vantage Medical Group Senior |
$7,613.89
|
|
|
PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION [95849]
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS J2562
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$631.32 |
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$653.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$309.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$35.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$631.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$631.32
|
| Rate for Payer: Blue Shield of California Commercial |
$36.61
|
| Rate for Payer: Blue Shield of California Commercial |
$36.61
|
| Rate for Payer: Blue Shield of California EPN |
$36.61
|
| Rate for Payer: Blue Shield of California EPN |
$36.61
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$230.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$486.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$320.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$676.48
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.49
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$231.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$489.39
|
| Rate for Payer: Heritage Provider Network Senior |
$231.50
|
| Rate for Payer: Heritage Provider Network Senior |
$489.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$238.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$504.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$191.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$32.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$32.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$38.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$38.18
|
| Rate for Payer: Multiplan Commercial |
$375.00
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$422.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$200.00
|
| Rate for Payer: TriValley Medical Group Senior |
$422.80
|
| Rate for Payer: TriValley Medical Group Senior |
$200.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$381.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$165.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$349.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.34
|
| Rate for Payer: Vantage Medical Group Senior |
$31.34
|
| Rate for Payer: Vantage Medical Group Senior |
$31.34
|
|
|
PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION [95849]
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS J2562
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.32 |
| Max. Negotiated Rate |
$792.75 |
| Rate for Payer: Adventist Health Commercial |
$211.40
|
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$322.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$680.71
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$475.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$486.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$230.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$570.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$270.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$489.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$231.50
|
| Rate for Payer: Heritage Provider Network Senior |
$231.50
|
| Rate for Payer: Heritage Provider Network Senior |
$489.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$191.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.00
|
| Rate for Payer: Multiplan Commercial |
$375.00
|
| Rate for Payer: Multiplan Commercial |
$792.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$381.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$165.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$349.97
|
|
|
PLEURAL EFFUSION WITH CC
|
Facility
|
IP
|
$15,889.69
|
|
|
Service Code
|
MSDRG 187
|
| Min. Negotiated Rate |
$11,857.98 |
| Max. Negotiated Rate |
$15,889.69 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,857.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,857.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,636.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,889.69
|
|
|
PLEURAL EFFUSION WITH MCC
|
Facility
|
IP
|
$24,633.10
|
|
|
Service Code
|
MSDRG 186
|
| Min. Negotiated Rate |
$18,382.91 |
| Max. Negotiated Rate |
$24,633.10 |
| Rate for Payer: EPIC Health Plan Medicare |
$18,382.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,382.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,140.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,633.10
|
|
|
PLEURAL EFFUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$11,714.53
|
|
|
Service Code
|
MSDRG 188
|
| Min. Negotiated Rate |
$8,742.19 |
| Max. Negotiated Rate |
$11,714.53 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,742.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,742.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,053.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,714.53
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
OP
|
$759.38
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.45 |
| Max. Negotiated Rate |
$645.47 |
| Rate for Payer: Adventist Health Commercial |
$151.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$469.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$645.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$417.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$569.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$575.83
|
| Rate for Payer: Blue Shield of California Commercial |
$266.70
|
| Rate for Payer: Blue Shield of California EPN |
$266.70
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$645.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$645.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$645.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$486.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.59
|
| Rate for Payer: Heritage Provider Network Senior |
$351.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$362.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$531.57
|
| Rate for Payer: Multiplan Commercial |
$569.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$303.75
|
| Rate for Payer: TriValley Medical Group Senior |
$303.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$645.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$645.47
|
| Rate for Payer: Vantage Medical Group Senior |
$645.47
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
IP
|
$759.38
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.45 |
| Max. Negotiated Rate |
$569.53 |
| Rate for Payer: Adventist Health Commercial |
$151.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$489.04
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$410.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.59
|
| Rate for Payer: Heritage Provider Network Senior |
$351.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.84
|
| Rate for Payer: Multiplan Commercial |
$569.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.43
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$180.96
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.10
|
| Rate for Payer: Heritage Provider Network Senior |
$130.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.25
|
| Rate for Payer: Multiplan Commercial |
$210.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$101.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.04
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.15 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$173.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.15
|
| Rate for Payer: Blue Shield of California Commercial |
$119.42
|
| Rate for Payer: Blue Shield of California EPN |
$119.42
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.10
|
| Rate for Payer: Heritage Provider Network Senior |
$130.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$134.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$210.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$112.40
|
| Rate for Payer: TriValley Medical Group Senior |
$112.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$101.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$210.74 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$180.96
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$151.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.10
|
| Rate for Payer: Heritage Provider Network Senior |
$130.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.25
|
| Rate for Payer: Multiplan Commercial |
$210.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$101.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.04
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.15 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$173.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$42.15
|
| Rate for Payer: Blue Shield of California Commercial |
$119.42
|
| Rate for Payer: Blue Shield of California EPN |
$119.42
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cash Price |
$126.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$179.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.10
|
| Rate for Payer: Heritage Provider Network Senior |
$130.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$134.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$50.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$210.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$112.40
|
| Rate for Payer: TriValley Medical Group Senior |
$112.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$101.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$17,581.86
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$13,120.79 |
| Max. Negotiated Rate |
$17,581.86 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,120.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,120.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,088.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17,581.86
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$27,790.21
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$20,738.96 |
| Max. Negotiated Rate |
$27,790.21 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,738.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,738.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,849.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,790.21
|
|
