|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$9,881.00
|
|
|
Service Code
|
ICD 021W08P
|
| Min. Negotiated Rate |
$9,881.00 |
| Max. Negotiated Rate |
$9,881.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
|
|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$9,881.00
|
|
|
Service Code
|
ICD 0JPT3FZ
|
| Min. Negotiated Rate |
$9,881.00 |
| Max. Negotiated Rate |
$9,881.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
|
|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$9,881.00
|
|
|
Service Code
|
ICD 02LH0DZ
|
| Min. Negotiated Rate |
$9,881.00 |
| Max. Negotiated Rate |
$9,881.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
|
|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$19,726.00
|
|
|
Service Code
|
ICD 02C13ZZ
|
| Min. Negotiated Rate |
$4,519.00 |
| Max. Negotiated Rate |
$19,726.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
| Rate for Payer: Blue Shield of California Commercial |
$19,726.00
|
| Rate for Payer: Blue Shield of California EPN |
$16,911.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,968.00
|
| Rate for Payer: Heritage Provider Network Senior |
$4,519.00
|
|
|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$9,881.00
|
|
|
Service Code
|
ICD 04CP3ZZ
|
| Min. Negotiated Rate |
$9,881.00 |
| Max. Negotiated Rate |
$9,881.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
|
|
Cardiovascular Surgery - #2075
|
Facility
IP
|
$9,881.00
|
|
|
Service Code
|
ICD X2C2361
|
| Min. Negotiated Rate |
$9,881.00 |
| Max. Negotiated Rate |
$9,881.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,881.00
|
|
|
CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [222456]
|
Facility
OP
|
$595.84
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
ERX222456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$446.88 |
| Rate for Payer: Adventist Health Commercial |
$119.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$92.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$409.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$58.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$51.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$51.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.01
|
| Rate for Payer: Blue Shield of California Commercial |
$47.82
|
| Rate for Payer: Blue Shield of California EPN |
$47.82
|
| Rate for Payer: Cash Price |
$268.13
|
| Rate for Payer: Cash Price |
$268.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$274.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.79
|
| Rate for Payer: Dignity Health Senior |
$51.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$381.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$47.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$275.87
|
| Rate for Payer: Heritage Provider Network Senior |
$275.87
|
| Rate for Payer: Humana Medicare |
$47.08
|
| Rate for Payer: IEHP Medi-Cal |
$80.42
|
| Rate for Payer: IEHP Medicare Advantage |
$47.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$89.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.33
|
| Rate for Payer: Multiplan Commercial |
$446.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.79
|
| Rate for Payer: TriValley Medical Group Senior |
$47.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$70.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.79
|
| Rate for Payer: Vantage Medical Group Senior |
$47.08
|
|
|
CARFILZOMIB 10 MG INTRAVENOUS SOLUTION [222456]
|
Facility
IP
|
$595.84
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
ERX222456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.85 |
| Max. Negotiated Rate |
$446.88 |
| Rate for Payer: Adventist Health Commercial |
$119.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$409.34
|
| Rate for Payer: Cash Price |
$268.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$274.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$321.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$403.38
|
| Rate for Payer: Heritage Provider Network Senior |
$403.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$148.96
|
| Rate for Payer: Multiplan Commercial |
$446.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.07
|
|
|
CARFILZOMIB 30 MG INTRAVENOUS SOLUTION [214890]
|
Facility
OP
|
$1,787.52
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
ERX214890
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$1,340.64 |
| Rate for Payer: Adventist Health Commercial |
$357.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$92.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,228.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$58.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$51.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$51.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.01
|
| Rate for Payer: Blue Shield of California Commercial |
$47.82
|
| Rate for Payer: Blue Shield of California EPN |
$47.82
|
| Rate for Payer: Cash Price |
$804.38
|
| Rate for Payer: Cash Price |
$804.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$822.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.79
|
| Rate for Payer: Dignity Health Senior |
$51.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,144.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$47.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$827.62
|
| Rate for Payer: Heritage Provider Network Senior |
$827.62
|
| Rate for Payer: Humana Medicare |
$47.08
|
| Rate for Payer: IEHP Medi-Cal |
$80.42
|
| Rate for Payer: IEHP Medicare Advantage |
$47.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$89.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$323.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$446.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.33
|
| Rate for Payer: Multiplan Commercial |
$1,340.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.79
|
| Rate for Payer: TriValley Medical Group Senior |
$47.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$651.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$597.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$70.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.79
|
| Rate for Payer: Vantage Medical Group Senior |
$47.08
|
|
|
CARFILZOMIB 30 MG INTRAVENOUS SOLUTION [214890]
|
Facility
IP
|
$1,787.52
|
|
|
Service Code
|
CPT J9047
|
| Hospital Charge Code |
ERX214890
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$323.54 |
| Max. Negotiated Rate |
$1,340.64 |
| Rate for Payer: Adventist Health Commercial |
$357.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,228.03
|
| Rate for Payer: Cash Price |
$804.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$822.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$965.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,210.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1,210.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$323.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$446.88
|
| Rate for Payer: Multiplan Commercial |
$1,340.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$651.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$597.21
|
|
|
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION [196893]
|
Facility
OP
|
$3,575.04
|
|
|
Service Code
|
NDC 76075-101-01
|
| Hospital Charge Code |
1755799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$647.08 |
| Max. Negotiated Rate |
$3,038.78 |
| Rate for Payer: Adventist Health Commercial |
$715.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,910.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,456.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,966.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,681.28
|
| Rate for Payer: Blue Shield of California Commercial |
$2,220.10
|
| Rate for Payer: Blue Shield of California EPN |
$2,098.55
|
| Rate for Payer: Cash Price |
$1,608.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,644.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,038.78
|
| Rate for Payer: Dignity Health Senior |
$3,038.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,288.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,655.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1,655.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,723.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$647.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$893.76
|
| Rate for Payer: Multiplan Commercial |
$2,681.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,303.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,194.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,038.78
|
| Rate for Payer: Vantage Medical Group Senior |
$3,038.78
|
|
|
CARFILZOMIB 60 MG INTRAVENOUS SOLUTION [196893]
|
Facility
IP
|
$3,575.04
|
|
|
Service Code
|
NDC 76075-101-01
|
| Hospital Charge Code |
1755799
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$647.08 |
| Max. Negotiated Rate |
$2,681.28 |
| Rate for Payer: Adventist Health Commercial |
$715.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,456.05
|
| Rate for Payer: Cash Price |
$1,608.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,644.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,930.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,420.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,420.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$647.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$893.76
|
| Rate for Payer: Multiplan Commercial |
$2,681.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,303.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,194.42
|
|
|
CARISOPRODOL 350 MG TABLET [1395]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 69584-111-10
|
| Hospital Charge Code |
1711179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
CARISOPRODOL 350 MG TABLET [1395]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 50228-109-01
|
| Hospital Charge Code |
1711179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
CARISOPRODOL 350 MG TABLET [1395]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 50228-109-01
|
| Hospital Charge Code |
1711179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
CARISOPRODOL 350 MG TABLET [1395]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 69584-111-10
|
| Hospital Charge Code |
1711179
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
CARMUSTINE 100 MG INTRAVENOUS SOLUTION [28911]
|
Facility
OP
|
$900.00
|
|
|
Service Code
|
CPT J9050
|
| Hospital Charge Code |
1755109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$1,008.80 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$534.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$339.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$298.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$298.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$238.66
|
| Rate for Payer: Blue Shield of California Commercial |
$1,008.80
|
| Rate for Payer: Blue Shield of California EPN |
$1,008.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$407.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$298.61
|
| Rate for Payer: Dignity Health Senior |
$298.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$576.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$271.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$416.70
|
| Rate for Payer: Heritage Provider Network Senior |
$416.70
|
| Rate for Payer: Humana Medicare |
$271.46
|
| Rate for Payer: IEHP Medi-Cal |
$430.45
|
| Rate for Payer: IEHP Medicare Advantage |
$271.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$515.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$320.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$342.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$342.05
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$298.61
|
| Rate for Payer: TriValley Medical Group Senior |
$271.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$407.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$298.61
|
| Rate for Payer: Vantage Medical Group Senior |
$271.46
|
|
|
CARMUSTINE 100 MG INTRAVENOUS SOLUTION [28911]
|
Facility
IP
|
$900.00
|
|
|
Service Code
|
CPT J9050
|
| Hospital Charge Code |
1755109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$486.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$609.30
|
| Rate for Payer: Heritage Provider Network Senior |
$609.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
|
|
Carpectomy; 1 bone
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25210
|
| Min. Negotiated Rate |
$92.35 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: IEHP Medi-Cal |
$92.35
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Carpectomy; all bones of proximal row
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 25215
|
| Min. Negotiated Rate |
$658.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: IEHP Medi-Cal |
$658.04
|
| Rate for Payer: IEHP Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Cartilage graft; costochondral
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20910
|
| Min. Negotiated Rate |
$330.47 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$330.47
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Cartilage graft; nasal septum
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 20912
|
| Min. Negotiated Rate |
$139.39 |
| 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 |
$5,505.00
|
| 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 |
$139.39
|
| 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
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|
|
CARVEDILOL 12.5 MG TABLET [15749]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 68382-094-01
|
| Hospital Charge Code |
1711679
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
CARVEDILOL 12.5 MG TABLET [15749]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 65862-144-01
|
| Hospital Charge Code |
1711679
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
CARVEDILOL 12.5 MG TABLET [15749]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0904-6302-61
|
| Hospital Charge Code |
1711679
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
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