|
Plastic repair of introitus
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 56800
|
| Min. Negotiated Rate |
$379.42 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: IEHP Medi-Cal |
$379.42
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,421.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,296.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,906.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
Plastic repair of salivary duct, sialodochoplasty; primary or simple
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 42500
|
| Min. Negotiated Rate |
$3,728.00 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Plastic repair of salivary duct, sialodochoplasty; secondary or complicated
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 42505
|
| Min. Negotiated Rate |
$603.44 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: IEHP Medi-Cal |
$603.44
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [103895]
|
Facility
OP
|
$541.63
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
1721197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.04 |
| Max. Negotiated Rate |
$627.51 |
| Rate for Payer: Adventist Health Commercial |
$108.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$627.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$460.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$297.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$406.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$249.94
|
| Rate for Payer: Blue Shield of California Commercial |
$230.83
|
| Rate for Payer: Blue Shield of California EPN |
$230.83
|
| Rate for Payer: Cash Price |
$243.73
|
| Rate for Payer: Cash Price |
$243.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$460.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$460.39
|
| Rate for Payer: Dignity Health Senior |
$460.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$346.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.77
|
| Rate for Payer: Heritage Provider Network Senior |
$250.77
|
| Rate for Payer: IEHP Medi-Cal |
$409.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$261.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.41
|
| Rate for Payer: Multiplan Commercial |
$406.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$197.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$460.39
|
| Rate for Payer: Vantage Medical Group Senior |
$460.39
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [103895]
|
Facility
IP
|
$541.63
|
|
|
Service Code
|
CPT 90670
|
| Hospital Charge Code |
1721197
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.04 |
| Max. Negotiated Rate |
$406.22 |
| Rate for Payer: Adventist Health Commercial |
$108.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.10
|
| Rate for Payer: Cash Price |
$243.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$366.68
|
| Rate for Payer: Heritage Provider Network Senior |
$366.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.41
|
| Rate for Payer: Multiplan Commercial |
$406.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$197.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.96
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
OP
|
$626.81
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
NDG231988A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.45 |
| Max. Negotiated Rate |
$702.11 |
| Rate for Payer: Adventist Health Commercial |
$125.36
|
| Rate for Payer: Adventist Health Commercial |
$121.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$702.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$702.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$417.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$430.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$532.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$516.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$334.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$344.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$470.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$455.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$507.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$507.64
|
| Rate for Payer: Blue Shield of California Commercial |
$253.85
|
| Rate for Payer: Blue Shield of California Commercial |
$253.85
|
| Rate for Payer: Blue Shield of California EPN |
$253.85
|
| Rate for Payer: Blue Shield of California EPN |
$253.85
|
| Rate for Payer: Cash Price |
$273.47
|
| Rate for Payer: Cash Price |
$273.47
|
| Rate for Payer: Cash Price |
$282.06
|
| Rate for Payer: Cash Price |
$282.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$288.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$279.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$532.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$516.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$516.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$532.79
|
| Rate for Payer: Dignity Health Senior |
$516.55
|
| Rate for Payer: Dignity Health Senior |
$532.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$401.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$388.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$290.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$281.37
|
| Rate for Payer: Heritage Provider Network Senior |
$290.21
|
| Rate for Payer: Heritage Provider Network Senior |
$281.37
|
| Rate for Payer: IEHP Medi-Cal |
$457.27
|
| Rate for Payer: IEHP Medi-Cal |
$457.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$292.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$302.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$113.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.93
|
| Rate for Payer: Multiplan Commercial |
$470.11
|
| Rate for Payer: Multiplan Commercial |
$455.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$228.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$516.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$532.79
|
| Rate for Payer: Vantage Medical Group Senior |
$532.79
|
| Rate for Payer: Vantage Medical Group Senior |
$516.55
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
IP
|
$626.81
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
NDG231988A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.45 |
| Max. Negotiated Rate |
$470.11 |
| Rate for Payer: Adventist Health Commercial |
$125.36
|
| Rate for Payer: Adventist Health Commercial |
$121.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$417.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$430.62
|
| Rate for Payer: Cash Price |
$273.47
|
| Rate for Payer: Cash Price |
$282.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$279.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$288.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$328.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$338.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$411.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$424.35
|
| Rate for Payer: Heritage Provider Network Senior |
$411.42
|
| Rate for Payer: Heritage Provider Network Senior |
$424.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$113.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$110.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$156.70
|
| Rate for Payer: Multiplan Commercial |
$470.11
|
| Rate for Payer: Multiplan Commercial |
$455.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$228.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$209.42
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SOLUTION [11037]
|
Facility
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.16 |
| Max. Negotiated Rate |
$324.64 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$324.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.16
|
| Rate for Payer: Blue Shield of California Commercial |
$119.43
|
| Rate for Payer: Blue Shield of California EPN |
$119.43
|
| 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 Senior |
$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: IEHP Medi-Cal |
$215.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.44
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
| 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 SOLUTION [11037]
|
Facility
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
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 |
$193.04
|
| 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 |
$190.23
|
| Rate for Payer: Heritage Provider Network Senior |
$190.23
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.16 |
| Max. Negotiated Rate |
$324.64 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$324.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.16
|
| Rate for Payer: Blue Shield of California Commercial |
$119.43
|
| Rate for Payer: Blue Shield of California EPN |
$119.43
|
| 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 Senior |
$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: IEHP Medi-Cal |
$215.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.44
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
| 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 SYRINGE [113995]
|
Facility
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
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 |
$193.04
|
| 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 |
$190.23
|
| Rate for Payer: Heritage Provider Network Senior |
$190.23
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.16 |
| Max. Negotiated Rate |
$324.64 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$324.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.16
|
| Rate for Payer: Blue Shield of California Commercial |
$119.43
|
| Rate for Payer: Blue Shield of California EPN |
$119.43
|
| 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 Senior |
$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: IEHP Medi-Cal |
$215.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.44
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
| 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
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
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 |
$193.04
|
| 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 |
$190.23
|
| Rate for Payer: Heritage Provider Network Senior |
$190.23
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
IP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
1720337
|
|
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 |
$193.04
|
| 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 |
$190.23
|
| Rate for Payer: Heritage Provider Network Senior |
$190.23
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
OP
|
$280.99
|
|
|
Service Code
|
CPT 90732
|
| Hospital Charge Code |
NDG11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.16 |
| Max. Negotiated Rate |
$324.64 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$324.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$37.16
|
| Rate for Payer: Blue Shield of California Commercial |
$119.43
|
| Rate for Payer: Blue Shield of California EPN |
$119.43
|
| 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 Senior |
$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: IEHP Medi-Cal |
$215.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.44
|
| Rate for Payer: Kaiser Permanente of CA 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 |
$102.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$93.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
IP
|
$11,598.50
|
|
|
Service Code
|
APR-DRG 8124
|
| Min. Negotiated Rate |
$11,598.50 |
| Max. Negotiated Rate |
$11,598.50 |
| Rate for Payer: IEHP Medi-Cal |
$11,598.50
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
IP
|
$3,119.00
|
|
|
Service Code
|
APR-DRG 8121
|
| Min. Negotiated Rate |
$3,119.00 |
| Max. Negotiated Rate |
$3,119.00 |
| Rate for Payer: IEHP Medi-Cal |
$3,119.00
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
IP
|
$6,519.55
|
|
|
Service Code
|
APR-DRG 8123
|
| Min. Negotiated Rate |
$6,519.55 |
| Max. Negotiated Rate |
$6,519.55 |
| Rate for Payer: IEHP Medi-Cal |
$6,519.55
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
IP
|
$4,450.17
|
|
|
Service Code
|
APR-DRG 8122
|
| Min. Negotiated Rate |
$4,450.17 |
| Max. Negotiated Rate |
$4,450.17 |
| Rate for Payer: IEHP Medi-Cal |
$4,450.17
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
IP
|
$19,860.05
|
|
|
Service Code
|
NDC 50242-105-01
|
| Hospital Charge Code |
ERX225066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,594.67 |
| Max. Negotiated Rate |
$14,895.04 |
| Rate for Payer: Adventist Health Commercial |
$3,972.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13,643.85
|
| Rate for Payer: Cash Price |
$8,937.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9,135.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,724.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,445.25
|
| Rate for Payer: Heritage Provider Network Senior |
$13,445.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,594.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,965.01
|
| Rate for Payer: Multiplan Commercial |
$14,895.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,240.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,635.24
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
OP
|
$19,860.05
|
|
|
Service Code
|
NDC 50242-105-01
|
| Hospital Charge Code |
ERX225066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,594.67 |
| Max. Negotiated Rate |
$16,881.04 |
| Rate for Payer: Adventist Health Commercial |
$3,972.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10,615.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13,643.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16,881.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10,923.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14,895.04
|
| Rate for Payer: Blue Shield of California Commercial |
$12,333.09
|
| Rate for Payer: Blue Shield of California EPN |
$11,657.85
|
| Rate for Payer: Cash Price |
$8,937.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9,135.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16,881.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$16,881.04
|
| Rate for Payer: Dignity Health Senior |
$16,881.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,710.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$9,195.20
|
| Rate for Payer: Heritage Provider Network Senior |
$9,195.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9,572.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,594.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4,965.01
|
| Rate for Payer: Multiplan Commercial |
$14,895.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,240.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,635.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16,881.04
|
| Rate for Payer: Vantage Medical Group Senior |
$16,881.04
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
OP
|
$95.74
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
1780065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$105.25 |
| Rate for Payer: Adventist Health Commercial |
$19.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$105.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$71.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$58.91
|
| Rate for Payer: Blue Shield of California Commercial |
$39.39
|
| Rate for Payer: Blue Shield of California EPN |
$39.39
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.38
|
| Rate for Payer: Dignity Health Senior |
$81.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.33
|
| Rate for Payer: Heritage Provider Network Senior |
$44.33
|
| Rate for Payer: IEHP Medi-Cal |
$72.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.94
|
| Rate for Payer: Multiplan Commercial |
$71.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.38
|
| Rate for Payer: Vantage Medical Group Senior |
$81.38
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
IP
|
$95.74
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
1780065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.33 |
| Max. Negotiated Rate |
$71.80 |
| Rate for Payer: Adventist Health Commercial |
$19.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.77
|
| Rate for Payer: Cash Price |
$43.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.82
|
| Rate for Payer: Heritage Provider Network Senior |
$64.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.94
|
| Rate for Payer: Multiplan Commercial |
$71.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.99
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 43386-312-08
|
| Hospital Charge Code |
NDG24984B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 45802-868-03
|
| Hospital Charge Code |
1713150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
