|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11010
|
| Min. Negotiated Rate |
$351.37 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$966.98
|
| Rate for Payer: Dignity Health Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$879.07
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$351.37
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,670.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,037.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,107.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,107.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$966.98
|
| Rate for Payer: TriValley Medical Group Senior |
$879.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11011
|
| Min. Negotiated Rate |
$440.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$879.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$966.98
|
| Rate for Payer: Dignity Health Senior |
$879.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$879.07
|
| Rate for Payer: Humana Medicare |
$879.07
|
| Rate for Payer: IEHP Medi-Cal |
$440.23
|
| Rate for Payer: IEHP Medicare Advantage |
$879.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,670.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,037.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,107.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,107.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$966.98
|
| Rate for Payer: TriValley Medical Group Senior |
$879.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,318.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$966.98
|
| Rate for Payer: Vantage Medical Group Senior |
$879.07
|
|
|
Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11012
|
| Min. Negotiated Rate |
$600.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,550.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,905.29
|
| Rate for Payer: Dignity Health Senior |
$3,550.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,550.26
|
| Rate for Payer: Humana Medicare |
$3,550.26
|
| Rate for Payer: IEHP Medi-Cal |
$600.54
|
| Rate for Payer: IEHP Medicare Advantage |
$3,550.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,745.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,189.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,473.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,473.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,905.29
|
| Rate for Payer: TriValley Medical Group Senior |
$3,550.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,325.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,905.29
|
| Rate for Payer: Vantage Medical Group Senior |
$3,550.26
|
|
|
Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11043
|
| Min. Negotiated Rate |
$244.51 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| 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 |
$4,547.00
|
| 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 |
$244.51
|
| 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
|
|
|
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11045
|
| Min. Negotiated Rate |
$22.78 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$22.78
|
|
|
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 11042
|
| Min. Negotiated Rate |
$162.04 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: IEHP Medi-Cal |
$162.04
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
IP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$351.85 |
| Max. Negotiated Rate |
$1,457.96 |
| Rate for Payer: Adventist Health Commercial |
$388.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,335.49
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,049.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,316.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,316.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$351.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.99
|
| Rate for Payer: Multiplan Commercial |
$1,457.96
|
|
|
DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]
|
Facility
OP
|
$1,943.95
|
|
|
Service Code
|
NDC 64842-0727-9
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$351.85 |
| Max. Negotiated Rate |
$1,652.36 |
| Rate for Payer: Adventist Health Commercial |
$388.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,039.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,335.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,652.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,069.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,457.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1,207.19
|
| Rate for Payer: Blue Shield of California EPN |
$1,141.10
|
| Rate for Payer: Cash Price |
$874.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,263.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,652.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,652.36
|
| Rate for Payer: Dignity Health Senior |
$1,652.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,244.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,203.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1,203.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$936.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$351.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$485.99
|
| Rate for Payer: Multiplan Commercial |
$1,457.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,652.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1,652.36
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$163.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$494.64
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$388.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$160.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$487.44
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$487.44
|
| Rate for Payer: Heritage Provider Network Senior |
$160.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$262.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$240.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT J0894
|
| Hospital Charge Code |
1755761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Adventist Health Commercial |
$47.52
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Adventist Health Commercial |
$144.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$494.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$163.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$102.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$201.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$612.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$66.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$130.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$396.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$90.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$178.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$540.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$53.47
|
| Rate for Payer: Blue Shield of California Commercial |
$7.65
|
| Rate for Payer: Blue Shield of California Commercial |
$7.65
|
| Rate for Payer: Blue Shield of California Commercial |
$7.65
|
| Rate for Payer: Blue Shield of California Commercial |
$7.65
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$106.92
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$331.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$201.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$612.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$201.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$612.00
|
| Rate for Payer: Dignity Health Senior |
$612.00
|
| Rate for Payer: Dignity Health Senior |
$201.96
|
| Rate for Payer: Dignity Health Senior |
$102.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$460.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$333.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$333.36
|
| Rate for Payer: Heritage Provider Network Senior |
$55.56
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: IEHP Medi-Cal |
$9.59
|
| Rate for Payer: IEHP Medi-Cal |
$9.59
|
| Rate for Payer: IEHP Medi-Cal |
$9.59
|
| Rate for Payer: IEHP Medi-Cal |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$347.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$114.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$180.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.40
|
| Rate for Payer: Multiplan Commercial |
$540.00
|
| Rate for Payer: Multiplan Commercial |
$178.20
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$262.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$79.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$240.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$612.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$201.96
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$102.00
|
| Rate for Payer: Vantage Medical Group Senior |
$612.00
|
| Rate for Payer: Vantage Medical Group Senior |
$201.96
|
|
|
Decompressive fasciotomy, hand (excludes 26035)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26037
|
| Min. Negotiated Rate |
$484.38 |
| 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 |
$484.38
|
| 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
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$87.71 |
| Rate for Payer: Adventist Health Commercial |
$23.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.34
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.18
|
| Rate for Payer: Heritage Provider Network Senior |
$79.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.24
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
|
|
DEFERASIROX 180 MG TABLET [206427]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0655-15
|
| Hospital Charge Code |
ERX206427
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Adventist Health Commercial |
$23.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$87.71
|
| Rate for Payer: Blue Shield of California Commercial |
$72.63
|
| Rate for Payer: Blue Shield of California EPN |
$68.65
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: Dignity Health Senior |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$74.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.39
|
| Rate for Payer: Heritage Provider Network Senior |
$72.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.24
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$87.71 |
| Rate for Payer: Adventist Health Commercial |
$23.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.34
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.18
|
| Rate for Payer: Heritage Provider Network Senior |
$79.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.24
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$116.95
|
|
|
Service Code
|
NDC 0078-0469-15
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.17 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Adventist Health Commercial |
$23.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$87.71
|
| Rate for Payer: Blue Shield of California Commercial |
$72.63
|
| Rate for Payer: Blue Shield of California EPN |
$68.65
|
| Rate for Payer: Cash Price |
$52.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.41
|
| Rate for Payer: Dignity Health Senior |
$99.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$74.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.39
|
| Rate for Payer: Heritage Provider Network Senior |
$72.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.24
|
| Rate for Payer: Multiplan Commercial |
$87.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.41
|
| Rate for Payer: Vantage Medical Group Senior |
$99.41
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
OP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$51.07 |
| Rate for Payer: Adventist Health Commercial |
$12.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.06
|
| Rate for Payer: Blue Shield of California Commercial |
$37.31
|
| Rate for Payer: Blue Shield of California EPN |
$35.27
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.07
|
| Rate for Payer: Dignity Health Senior |
$51.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.19
|
| Rate for Payer: Heritage Provider Network Senior |
$37.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.02
|
| Rate for Payer: Multiplan Commercial |
$45.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.07
|
| Rate for Payer: Vantage Medical Group Senior |
$51.07
|
|
|
DEFERASIROX 250 MG DISPERSIBLE TABLET [43416]
|
Facility
IP
|
$60.08
|
|
|
Service Code
|
NDC 45963-455-30
|
| Hospital Charge Code |
1712350
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$45.06 |
| Rate for Payer: Adventist Health Commercial |
$12.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.27
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.67
|
| Rate for Payer: Heritage Provider Network Senior |
$40.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.02
|
| Rate for Payer: Multiplan Commercial |
$45.06
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
IP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$175.42 |
| Rate for Payer: Adventist Health Commercial |
$46.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$160.68
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$126.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$158.34
|
| Rate for Payer: Heritage Provider Network Senior |
$158.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.47
|
| Rate for Payer: Multiplan Commercial |
$175.42
|
|
|
DEFERASIROX 500 MG DISPERSIBLE TABLET [43417]
|
Facility
OP
|
$233.89
|
|
|
Service Code
|
NDC 0078-0470-15
|
| Hospital Charge Code |
1712351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Adventist Health Commercial |
$46.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$125.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$160.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$198.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$128.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$175.42
|
| Rate for Payer: Blue Shield of California Commercial |
$145.25
|
| Rate for Payer: Blue Shield of California EPN |
$137.29
|
| Rate for Payer: Cash Price |
$105.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$152.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$198.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$198.81
|
| Rate for Payer: Dignity Health Senior |
$198.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$144.78
|
| Rate for Payer: Heritage Provider Network Senior |
$144.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$112.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.47
|
| Rate for Payer: Multiplan Commercial |
$175.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$198.81
|
| Rate for Payer: Vantage Medical Group Senior |
$198.81
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
OP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$42.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$27.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.95
|
| Rate for Payer: Blue Shield of California Commercial |
$11.41
|
| Rate for Payer: Blue Shield of California EPN |
$11.41
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.02
|
| Rate for Payer: Dignity Health Senior |
$42.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.89
|
| Rate for Payer: Heritage Provider Network Senior |
$22.89
|
| Rate for Payer: IEHP Medi-Cal |
$20.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.02
|
| Rate for Payer: Vantage Medical Group Senior |
$42.02
|
|
|
DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION [9722]
|
Facility
IP
|
$49.44
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1712428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$37.08 |
| Rate for Payer: Adventist Health Commercial |
$9.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$33.97
|
| Rate for Payer: Cash Price |
$22.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.47
|
| Rate for Payer: Heritage Provider Network Senior |
$33.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Multiplan Commercial |
$37.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.52
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$28.95 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.95
|
| Rate for Payer: Blue Shield of California Commercial |
$11.41
|
| Rate for Payer: Blue Shield of California EPN |
$11.41
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Senior |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: IEHP Medi-Cal |
$20.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
|
DEFEROXAMINE 500 MG SOLN FOR INJ (MIXTURE COMPONENT) [408000012]
|
Facility
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.68
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.19
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
IP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.68
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.52
|
| Rate for Payer: Heritage Provider Network Senior |
$10.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.19
|
|
|
DEFEROXAMINE 500 MG SOLUTION FOR INJECTION [9723]
|
Facility
OP
|
$15.54
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
1720046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$28.95 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.55
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.95
|
| Rate for Payer: Blue Shield of California Commercial |
$11.41
|
| Rate for Payer: Blue Shield of California EPN |
$11.41
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.21
|
| Rate for Payer: Dignity Health Senior |
$13.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.20
|
| Rate for Payer: Heritage Provider Network Senior |
$7.20
|
| Rate for Payer: IEHP Medi-Cal |
$20.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.21
|
| Rate for Payer: Vantage Medical Group Senior |
$13.21
|
|
