|
ADAGRASIB 200 MG TABLET [236395]
|
Facility
|
IP
|
$153.63
|
|
|
Service Code
|
NDC 8073981218
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.81 |
| Max. Negotiated Rate |
$115.22 |
| Rate for Payer: Adventist Health Commercial |
$30.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$98.94
|
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.01
|
| Rate for Payer: Heritage Provider Network Senior |
$104.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.41
|
| Rate for Payer: Multiplan Commercial |
$115.22
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
OP
|
$6.03
|
|
|
Service Code
|
NDC 4580245384
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.02
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.73
|
| Rate for Payer: Heritage Provider Network Senior |
$3.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.22
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.41
|
| Rate for Payer: TriValley Medical Group Senior |
$2.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
ADAPALENE 0.1 % TOPICAL CREAM [21831]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
NDC 4580245384
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.88
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.08
|
| Rate for Payer: Heritage Provider Network Senior |
$4.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.52
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.23
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [39477]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
IP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$4.93 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.23
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
|
|
ADENOSINE 6 MG/2 ML VIAL - CODE [4080560]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.63
|
| Rate for Payer: TriValley Medical Group Senior |
$2.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.58
|
| Rate for Payer: Vantage Medical Group Senior |
$5.58
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.00
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.31
|
| Rate for Payer: Heritage Provider Network Senior |
$3.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.57
|
|
|
ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION [15330]
|
Facility
|
OP
|
$7.15
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Adventist Health Commercial |
$1.43
|
| Rate for Payer: Adventist Health Commercial |
$1.14
|
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.85
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.86
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Senior |
$3.31
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.83
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$4.29
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.29
|
| Rate for Payer: TriValley Medical Group Senior |
$2.29
|
| Rate for Payer: TriValley Medical Group Senior |
$3.10
|
| Rate for Payer: TriValley Medical Group Senior |
$2.86
|
| Rate for Payer: TriValley Medical Group Senior |
$1.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.26
|
| Rate for Payer: Vantage Medical Group Senior |
$6.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.86
|
| Rate for Payer: Vantage Medical Group Senior |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$3.26
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 14301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,557.82 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,435.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,557.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5,606.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8,659.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,241.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,013.60
|
| Rate for Payer: TriValley Medical Group Senior |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14302
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14041
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14021
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 14000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,653.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,653.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| 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 |
$3,980.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,919.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,653.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,653.72
|
| Rate for Payer: Heritage Provider Network Senior |
$3,264.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,653.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,042.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,051.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,555.98
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,919.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,980.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,919.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2,653.72
|
|
|
ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 5816082903
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
ADJUVANT AS01B (PF), COMPONENT VIAL 1 OF 2 INTRAMUSCULAR SUSPENSION [219987]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 5816082903
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
|
IP
|
$4,979.06
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$901.21 |
| Max. Negotiated Rate |
$3,734.30 |
| Rate for Payer: Adventist Health Commercial |
$995.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,206.51
|
| Rate for Payer: Cash Price |
$2,240.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,290.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,688.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,305.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,305.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$901.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,244.77
|
| Rate for Payer: Multiplan Commercial |
$3,734.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,798.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,648.57
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [200177]
|
Facility
|
OP
|
$4,979.06
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.09 |
| Max. Negotiated Rate |
$3,734.30 |
| Rate for Payer: Adventist Health Commercial |
$995.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,077.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$65.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.25
|
| Rate for Payer: Blue Shield of California Commercial |
$40.09
|
| Rate for Payer: Blue Shield of California EPN |
$40.09
|
| Rate for Payer: Cash Price |
$2,240.58
|
| Rate for Payer: Cash Price |
$2,240.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,290.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,186.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,305.30
|
| Rate for Payer: Heritage Provider Network Senior |
$2,305.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,375.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$901.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,244.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.46
|
| Rate for Payer: Multiplan Commercial |
$3,734.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,991.62
|
| Rate for Payer: TriValley Medical Group Senior |
$1,991.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,798.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,648.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.99
|
| Rate for Payer: Vantage Medical Group Senior |
$47.99
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
|
IP
|
$7,966.49
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,441.93 |
| Max. Negotiated Rate |
$5,974.87 |
| Rate for Payer: Adventist Health Commercial |
$1,593.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,130.42
|
| Rate for Payer: Cash Price |
$3,584.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,664.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,301.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,688.48
|
| Rate for Payer: Heritage Provider Network Senior |
$3,688.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,441.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,991.62
|
| Rate for Payer: Multiplan Commercial |
$5,974.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,878.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,637.70
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [200178]
|
Facility
|
OP
|
$7,966.49
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.09 |
| Max. Negotiated Rate |
$5,974.87 |
| Rate for Payer: Adventist Health Commercial |
$1,593.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,923.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$65.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$43.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.25
|
| Rate for Payer: Blue Shield of California Commercial |
$40.09
|
| Rate for Payer: Blue Shield of California EPN |
$40.09
|
| Rate for Payer: Cash Price |
$3,584.92
|
| Rate for Payer: Cash Price |
$3,584.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,664.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$54.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,098.55
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,688.48
|
| Rate for Payer: Heritage Provider Network Senior |
$3,688.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,800.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,441.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,991.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$58.46
|
| Rate for Payer: Multiplan Commercial |
$5,974.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,186.60
|
| Rate for Payer: TriValley Medical Group Senior |
$3,186.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,878.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,637.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$54.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.99
|
| Rate for Payer: Vantage Medical Group Senior |
$47.99
|
|
