|
COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 9994080426
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC
|
Facility
|
IP
|
$118,097.20
|
|
|
Service Code
|
MSDRG 233
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$118,097.20 |
| Rate for Payer: EPIC Health Plan Medicare |
$88,132.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$88,132.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$101,352.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$118,097.20
|
|
|
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC
|
Facility
|
IP
|
$84,583.90
|
|
|
Service Code
|
MSDRG 234
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$84,583.90 |
| Rate for Payer: EPIC Health Plan Medicare |
$63,122.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63,122.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$72,590.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84,583.90
|
|
|
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC
|
Facility
|
IP
|
$90,816.68
|
|
|
Service Code
|
MSDRG 235
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$90,816.68 |
| Rate for Payer: EPIC Health Plan Medicare |
$67,773.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67,773.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$77,939.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$90,816.68
|
|
|
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC
|
Facility
|
IP
|
$65,022.58
|
|
|
Service Code
|
MSDRG 236
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$65,022.58 |
| Rate for Payer: EPIC Health Plan Medicare |
$48,524.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48,524.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55,802.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$65,022.58
|
|
|
CORONARY BYPASS WITH PTCA WITH MCC
|
Facility
|
IP
|
$130,146.63
|
|
|
Service Code
|
MSDRG 231
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$130,146.63 |
| Rate for Payer: EPIC Health Plan Medicare |
$97,124.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$97,124.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$111,693.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$130,146.63
|
|
|
CORONARY BYPASS WITH PTCA WITHOUT MCC
|
Facility
|
IP
|
$93,795.65
|
|
|
Service Code
|
MSDRG 232
|
| Min. Negotiated Rate |
$23,752.00 |
| Max. Negotiated Rate |
$93,795.65 |
| Rate for Payer: EPIC Health Plan Medicare |
$69,996.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$26,116.00
|
| Rate for Payer: Heritage Provider Network Senior |
$23,752.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$69,996.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$80,496.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$93,795.65
|
|
|
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC
|
Facility
|
IP
|
$67,150.84
|
|
|
Service Code
|
MSDRG 323
|
| Min. Negotiated Rate |
$50,112.57 |
| Max. Negotiated Rate |
$67,150.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$50,112.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$50,112.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$57,629.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67,150.84
|
|
|
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC
|
Facility
|
IP
|
$49,086.65
|
|
|
Service Code
|
MSDRG 324
|
| Min. Negotiated Rate |
$36,631.83 |
| Max. Negotiated Rate |
$49,086.65 |
| Rate for Payer: EPIC Health Plan Medicare |
$36,631.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$36,631.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42,126.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49,086.65
|
|
|
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE
|
Facility
|
IP
|
$49,998.79
|
|
|
Service Code
|
MSDRG 325
|
| Min. Negotiated Rate |
$37,312.53 |
| Max. Negotiated Rate |
$49,998.79 |
| Rate for Payer: EPIC Health Plan Medicare |
$37,312.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37,312.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42,909.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49,998.79
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 28296
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| 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 |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| 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 |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD
|
Facility
|
OP
|
$31,374.11
|
|
|
Service Code
|
CPT 28297
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$31,374.11 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24,769.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18,163.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16,512.69
|
| 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 |
$24,769.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,163.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16,512.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$16,512.69
|
| Rate for Payer: Heritage Provider Network Senior |
$20,310.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,512.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$31,374.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,989.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,127.00
|
| Rate for Payer: Multiplan WC |
$26,048.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,163.96
|
| Rate for Payer: TriValley Medical Group Senior |
$18,163.96
|
| 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 |
$24,769.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,163.96
|
| Rate for Payer: Vantage Medical Group Senior |
$16,512.69
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH PROXIMAL PHALANX OSTEOTOMY, ANY METHOD
|
Facility
|
OP
|
$17,732.13
|
|
|
Service Code
|
CPT 28298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$17,732.13 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9,332.70
|
| 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 |
$13,999.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,265.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,332.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$9,332.70
|
| Rate for Payer: Heritage Provider Network Senior |
$11,479.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,332.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17,732.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,732.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,505.82
|
| Rate for Payer: Multiplan WC |
$14,462.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,265.97
|
| Rate for Payer: TriValley Medical Group Senior |
$10,265.97
|
| 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 |
$13,999.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Vantage Medical Group Senior |
$9,332.70
|
|
|
CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH RESECTION OF PROXIMAL PHALANX BASE, WHEN PERFORMED, ANY METHOD
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 28292
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| 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 |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| 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 |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 28285
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,208.34 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,208.34
|
| 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 |
$6,312.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,629.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,208.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,208.34
|
| Rate for Payer: Heritage Provider Network Senior |
$5,176.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,208.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,995.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,839.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,639.18
|
| Rate for Payer: Multiplan WC |
$6,568.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,629.17
|
| Rate for Payer: TriValley Medical Group Senior |
$4,629.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,312.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,629.17
|
| Rate for Payer: Vantage Medical Group Senior |
$4,208.34
|
|
|
CORRECTION OF INVERTED NIPPLES
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 19355
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,035.90 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7,553.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,539.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5,035.90
|
| 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 |
$7,553.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,539.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5,035.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$5,035.90
|
| Rate for Payer: Heritage Provider Network Senior |
$6,194.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5,035.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9,568.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,791.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,748.11
|
| Rate for Payer: Multiplan WC |
$7,752.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,539.49
|
| Rate for Payer: TriValley Medical Group Senior |
$5,539.49
|
| 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 |
$7,553.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,539.49
|
| Rate for Payer: Vantage Medical Group Senior |
$5,035.90
|
|
|
CORTICOTROPIN 80 UNIT/ML INJECTION GEL [9685]
|
Facility
|
IP
|
$11,199.12
|
|
|
Service Code
|
HCPCS J0801
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,027.04 |
| Max. Negotiated Rate |
$8,399.34 |
| Rate for Payer: Adventist Health Commercial |
$2,239.82
|
| Rate for Payer: Adventist Health Commercial |
$1,633.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,260.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,212.23
|
| Rate for Payer: Cash Price |
$3,675.67
|
| Rate for Payer: Cash Price |
$5,039.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,151.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,757.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,047.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,410.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,185.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,781.86
|
| Rate for Payer: Heritage Provider Network Senior |
$3,781.86
|
| Rate for Payer: Heritage Provider Network Senior |
$5,185.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,478.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,027.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,799.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.04
|
| Rate for Payer: Multiplan Commercial |
$6,126.12
|
| Rate for Payer: Multiplan Commercial |
$8,399.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,046.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,951.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,704.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,708.03
|
|
|
CORTICOTROPIN 80 UNIT/ML INJECTION GEL [9685]
|
Facility
|
OP
|
$8,168.16
|
|
|
Service Code
|
HCPCS J0801
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,478.44 |
| Max. Negotiated Rate |
$10,351.98 |
| Rate for Payer: Adventist Health Commercial |
$1,633.63
|
| Rate for Payer: Adventist Health Commercial |
$2,239.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6,921.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,047.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,546.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,546.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,133.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,133.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,351.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,351.98
|
| Rate for Payer: Blue Shield of California Commercial |
$4,486.34
|
| Rate for Payer: Blue Shield of California Commercial |
$4,486.34
|
| Rate for Payer: Blue Shield of California EPN |
$4,486.34
|
| Rate for Payer: Blue Shield of California EPN |
$4,486.34
|
| Rate for Payer: Cash Price |
$3,675.67
|
| Rate for Payer: Cash Price |
$3,675.67
|
| Rate for Payer: Cash Price |
$5,039.60
|
| Rate for Payer: Cash Price |
$5,039.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,757.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,151.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,546.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,546.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,133.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,133.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,227.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$7,167.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,133.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,133.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,781.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,185.19
|
| Rate for Payer: Heritage Provider Network Senior |
$3,781.86
|
| Rate for Payer: Heritage Provider Network Senior |
$5,185.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,133.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,133.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,896.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5,341.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,027.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,478.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,753.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,753.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,042.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,799.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,538.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,538.82
|
| Rate for Payer: Multiplan Commercial |
$6,126.12
|
| Rate for Payer: Multiplan Commercial |
$8,399.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,479.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,267.26
|
| Rate for Payer: TriValley Medical Group Senior |
$4,479.65
|
| Rate for Payer: TriValley Medical Group Senior |
$3,267.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,951.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,046.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,704.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,708.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,200.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,546.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,546.80
|
| Rate for Payer: Vantage Medical Group Senior |
$4,133.45
|
| Rate for Payer: Vantage Medical Group Senior |
$4,133.45
|
|
|
COSIBELIMAB-IPDL 300 MG/5 ML (60 MG/ML) INTRAVENOUS SOLUTION [247041]
|
Facility
|
IP
|
$778.50
|
|
|
Service Code
|
HCPCS J9275
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.91 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Adventist Health Commercial |
$155.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$501.35
|
| Rate for Payer: Cash Price |
$350.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$358.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$420.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$360.45
|
| Rate for Payer: Heritage Provider Network Senior |
$360.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$140.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.62
|
| Rate for Payer: Multiplan Commercial |
$583.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$281.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$257.76
|
|
|
COSIBELIMAB-IPDL 300 MG/5 ML (60 MG/ML) INTRAVENOUS SOLUTION [247041]
|
Facility
|
OP
|
$778.50
|
|
|
Service Code
|
HCPCS J9275
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$583.88 |
| Rate for Payer: Adventist Health Commercial |
$155.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$481.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.48
|
| Rate for Payer: Blue Shield of California Commercial |
$474.88
|
| Rate for Payer: Blue Shield of California EPN |
$379.91
|
| Rate for Payer: Cash Price |
$350.32
|
| Rate for Payer: Cash Price |
$350.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$358.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$498.24
|
| Rate for Payer: EPIC Health Plan Medicare |
$22.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$360.45
|
| Rate for Payer: Heritage Provider Network Senior |
$360.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$371.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$140.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$29.84
|
| Rate for Payer: Multiplan Commercial |
$583.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$311.40
|
| Rate for Payer: TriValley Medical Group Senior |
$311.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$281.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$257.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.50
|
| Rate for Payer: Vantage Medical Group Senior |
$22.27
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
OP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$258.31 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$59.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$72.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.31
|
| Rate for Payer: Blue Shield of California Commercial |
$81.80
|
| Rate for Payer: Blue Shield of California EPN |
$81.80
|
| Rate for Payer: Cash Price |
$43.31
|
| Rate for Payer: Cash Price |
$43.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$81.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.56
|
| Rate for Payer: Heritage Provider Network Senior |
$44.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$67.37
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.50
|
| Rate for Payer: TriValley Medical Group Senior |
$38.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.80
|
| Rate for Payer: Vantage Medical Group Senior |
$81.80
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [9686]
|
Facility
|
IP
|
$96.24
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$72.18 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.98
|
| Rate for Payer: Cash Price |
$43.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.56
|
| Rate for Payer: Heritage Provider Network Senior |
$44.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Multiplan Commercial |
$72.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.87
|
|
|
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC
|
Facility
|
IP
|
$25,336.37
|
|
|
Service Code
|
MSDRG 073
|
| Min. Negotiated Rate |
$18,907.74 |
| Max. Negotiated Rate |
$25,336.37 |
| Rate for Payer: EPIC Health Plan Medicare |
$18,907.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,907.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,743.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25,336.37
|
|
|
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$16,530.03
|
|
|
Service Code
|
MSDRG 074
|
| Min. Negotiated Rate |
$12,335.84 |
| Max. Negotiated Rate |
$16,530.03 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,335.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,335.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14,186.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,530.03
|
|
|
CRANIECTOMY; FOR OSTEOMYELITIS
|
Facility
|
OP
|
$9,728.00
|
|
|
Service Code
|
CPT 61501
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,984.00 |
| Max. Negotiated Rate |
$9,728.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,728.00
|
| 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: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
|
