|
TROPICAMIDE 0.5 % EYE DROPS [8249]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 17478-101-12
|
| Hospital Charge Code |
1740094
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: Blue Distinction Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Media |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
TROPICAMIDE 0.5 % EYE DROPS [8249]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 17478-101-12
|
| Hospital Charge Code |
1740094
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
TROPICAMIDE 0.5 % EYE DROPS [8249]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
NDC 61314-354-01
|
| Hospital Charge Code |
1740094
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Distinction Transplant |
$1.03
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO |
$1.20
|
| Rate for Payer: Cigna of CA PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.45
|
| Rate for Payer: Dignity Health Media |
$1.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$1.45
|
| Rate for Payer: Global Benefits Group Commercial |
$1.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.37
|
| Rate for Payer: Networks By Design Commercial |
$1.11
|
| Rate for Payer: Prime Health Services Commercial |
$1.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.86
|
| Rate for Payer: United Healthcare All Other HMO |
$0.86
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.45
|
| Rate for Payer: Vantage Medical Group Senior |
$1.45
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 70069-121-01
|
| Hospital Charge Code |
1740096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: Blue Distinction Transplant |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Media |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 61314-355-02
|
| Hospital Charge Code |
1740096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Blue Shield of California Commercial |
$1.74
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
OP
|
$2.45
|
|
|
Service Code
|
NDC 61314-355-02
|
| Hospital Charge Code |
1740096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.46
|
| Rate for Payer: Blue Distinction Transplant |
$1.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.81
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$1.72
|
| Rate for Payer: Cigna of CA PPO |
$1.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.08
|
| Rate for Payer: Dignity Health Media |
$2.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.98
|
| Rate for Payer: Galaxy Health WC |
$2.08
|
| Rate for Payer: Global Benefits Group Commercial |
$1.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Networks By Design Commercial |
$1.59
|
| Rate for Payer: Prime Health Services Commercial |
$2.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare HMO Rider |
$1.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.08
|
| Rate for Payer: Vantage Medical Group Senior |
$2.08
|
|
|
TROPICAMIDE 1 % EYE DROPS [8250]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 70069-121-01
|
| Hospital Charge Code |
1740096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO |
$0.48
|
| Rate for Payer: Cigna of CA PPO |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
|
|
TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]
|
Facility
|
OP
|
$16.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG223020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.24
|
| Rate for Payer: Blue Distinction Transplant |
$10.08
|
| Rate for Payer: Blue Shield of California Commercial |
$12.38
|
| Rate for Payer: Blue Shield of California EPN |
$9.81
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cigna of CA HMO |
$11.76
|
| Rate for Payer: Cigna of CA PPO |
$11.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.28
|
| Rate for Payer: Dignity Health Media |
$14.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.72
|
| Rate for Payer: Galaxy Health WC |
$14.28
|
| Rate for Payer: Global Benefits Group Commercial |
$10.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.03
|
| Rate for Payer: Multiplan Commercial |
$13.44
|
| Rate for Payer: Networks By Design Commercial |
$8.40
|
| Rate for Payer: Prime Health Services Commercial |
$14.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.40
|
| Rate for Payer: United Healthcare All Other HMO |
$8.40
|
| Rate for Payer: United Healthcare HMO Rider |
$8.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.28
|
| Rate for Payer: Vantage Medical Group Senior |
$14.28
|
|
|
TROPICAMIDE 1 %-PROPARACAINE 0.5 %-PE 2.5 %-KETOROLAC 0.5 % EYE DROPS [223020]
|
Facility
|
IP
|
$16.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG223020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Blue Shield of California Commercial |
$11.96
|
| Rate for Payer: Blue Shield of California EPN |
$8.60
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cigna of CA HMO |
$11.76
|
| Rate for Payer: Cigna of CA PPO |
$11.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.72
|
| Rate for Payer: Galaxy Health WC |
$14.28
|
| Rate for Payer: Global Benefits Group Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.03
|
| Rate for Payer: Multiplan Commercial |
$13.44
|
| Rate for Payer: Networks By Design Commercial |
$8.40
|
| Rate for Payer: Prime Health Services Commercial |
$14.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.34
|
| Rate for Payer: United Healthcare All Other HMO |
$6.20
|
| Rate for Payer: United Healthcare HMO Rider |
$6.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.54
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]
|
Facility
|
IP
|
$177.84
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1740332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.68 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Blue Shield of California Commercial |
$126.62
|
| Rate for Payer: Blue Shield of California EPN |
$91.05
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cigna of CA HMO |
$124.49
|
| Rate for Payer: Cigna of CA PPO |
$124.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$71.14
|
| Rate for Payer: Galaxy Health WC |
$151.16
|
| Rate for Payer: Global Benefits Group Commercial |
$106.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$67.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.68
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Networks By Design Commercial |
$88.92
|
| Rate for Payer: Prime Health Services Commercial |
$151.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$67.15
|
| Rate for Payer: United Healthcare All Other HMO |
$65.59
|
| Rate for Payer: United Healthcare HMO Rider |
$64.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.69
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE [88317]
|
Facility
|
OP
|
$177.84
|
|
|
Service Code
|
CPT Q9968
|
| Hospital Charge Code |
1740332
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$151.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$121.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Distinction Transplant |
$106.70
|
| Rate for Payer: Blue Shield of California Commercial |
$131.07
|
| Rate for Payer: Blue Shield of California EPN |
$103.86
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cash Price |
$80.03
|
| Rate for Payer: Cigna of CA HMO |
$124.49
|
| Rate for Payer: Cigna of CA PPO |
$124.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.92
|
| Rate for Payer: Dignity Health Media |
$7.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.73
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.95
|
| Rate for Payer: Galaxy Health WC |
$151.16
|
| Rate for Payer: Global Benefits Group Commercial |
$106.70
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$133.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.04
|
| Rate for Payer: Heritage Provider Network Transplant |
$13.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$12.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$118.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.65
|
| Rate for Payer: Multiplan Commercial |
$142.27
|
| Rate for Payer: Networks By Design Commercial |
$88.92
|
| Rate for Payer: Prime Health Services Commercial |
$151.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$106.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$106.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$88.92
|
| Rate for Payer: United Healthcare All Other HMO |
$88.92
|
| Rate for Payer: United Healthcare HMO Rider |
$88.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$88.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.74
|
| Rate for Payer: Vantage Medical Group Senior |
$7.95
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
OP
|
$118.70
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
1720235
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$46.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.93
|
| Rate for Payer: Blue Distinction Transplant |
$71.22
|
| Rate for Payer: Blue Shield of California Commercial |
$76.68
|
| Rate for Payer: Blue Shield of California EPN |
$60.77
|
| Rate for Payer: Cash Price |
$53.42
|
| Rate for Payer: Cash Price |
$53.42
|
| Rate for Payer: Cigna of CA HMO |
$75.97
|
| Rate for Payer: Cigna of CA PPO |
$87.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Media |
$37.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.20
|
| Rate for Payer: Galaxy Health WC |
$100.90
|
| Rate for Payer: Global Benefits Group Commercial |
$71.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$89.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.01
|
| Rate for Payer: Heritage Provider Network Transplant |
$61.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$79.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$37.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Multiplan Commercial |
$94.96
|
| Rate for Payer: Networks By Design Commercial |
$77.16
|
| Rate for Payer: Prime Health Services Commercial |
$100.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$71.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$71.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.44
|
| Rate for Payer: United Healthcare All Other HMO |
$20.44
|
| Rate for Payer: United Healthcare HMO Rider |
$20.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
IP
|
$118.70
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
1720235
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Cash Price |
$53.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.48
|
| Rate for Payer: Galaxy Health WC |
$100.90
|
| Rate for Payer: Global Benefits Group Commercial |
$71.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$79.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$94.96
|
| Rate for Payer: Networks By Design Commercial |
$77.16
|
| Rate for Payer: Prime Health Services Commercial |
$100.90
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
IP
|
$113.05
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
NDG2224
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$27.13 |
| Max. Negotiated Rate |
$96.09 |
| Rate for Payer: Cash Price |
$50.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.22
|
| Rate for Payer: Galaxy Health WC |
$96.09
|
| Rate for Payer: Global Benefits Group Commercial |
$67.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.13
|
| Rate for Payer: Multiplan Commercial |
$90.44
|
| Rate for Payer: Networks By Design Commercial |
$73.48
|
| Rate for Payer: Prime Health Services Commercial |
$96.09
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
OP
|
$113.05
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
NDG2224
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$96.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$46.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.93
|
| Rate for Payer: Blue Distinction Transplant |
$67.83
|
| Rate for Payer: Blue Shield of California Commercial |
$73.03
|
| Rate for Payer: Blue Shield of California EPN |
$57.88
|
| Rate for Payer: Cash Price |
$50.87
|
| Rate for Payer: Cash Price |
$50.87
|
| Rate for Payer: Cigna of CA HMO |
$72.35
|
| Rate for Payer: Cigna of CA PPO |
$83.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Media |
$37.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.20
|
| Rate for Payer: Galaxy Health WC |
$96.09
|
| Rate for Payer: Global Benefits Group Commercial |
$67.83
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$84.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.01
|
| Rate for Payer: Heritage Provider Network Transplant |
$61.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$75.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$37.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Multiplan Commercial |
$90.44
|
| Rate for Payer: Networks By Design Commercial |
$73.48
|
| Rate for Payer: Prime Health Services Commercial |
$96.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$67.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$67.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.44
|
| Rate for Payer: United Healthcare All Other HMO |
$20.44
|
| Rate for Payer: United Healthcare HMO Rider |
$20.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
IP
|
$92.05
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
NDG8259
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$22.09 |
| Max. Negotiated Rate |
$78.24 |
| Rate for Payer: Cash Price |
$41.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.82
|
| Rate for Payer: Galaxy Health WC |
$78.24
|
| Rate for Payer: Global Benefits Group Commercial |
$55.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.09
|
| Rate for Payer: Multiplan Commercial |
$73.64
|
| Rate for Payer: Networks By Design Commercial |
$59.83
|
| Rate for Payer: Prime Health Services Commercial |
$78.24
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION [8259]
|
Facility
|
OP
|
$92.05
|
|
|
Service Code
|
CPT 86580
|
| Hospital Charge Code |
NDG8259
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$78.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$46.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.93
|
| Rate for Payer: Blue Distinction Transplant |
$55.23
|
| Rate for Payer: Blue Shield of California Commercial |
$59.46
|
| Rate for Payer: Blue Shield of California EPN |
$47.13
|
| Rate for Payer: Cash Price |
$41.42
|
| Rate for Payer: Cash Price |
$41.42
|
| Rate for Payer: Cigna of CA HMO |
$58.91
|
| Rate for Payer: Cigna of CA PPO |
$68.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Media |
$37.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.22
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$37.20
|
| Rate for Payer: Galaxy Health WC |
$78.24
|
| Rate for Payer: Global Benefits Group Commercial |
$55.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$69.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.01
|
| Rate for Payer: Heritage Provider Network Transplant |
$61.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$60.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$61.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$37.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$49.85
|
| Rate for Payer: Multiplan Commercial |
$73.64
|
| Rate for Payer: Networks By Design Commercial |
$59.83
|
| Rate for Payer: Prime Health Services Commercial |
$78.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$55.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$55.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.44
|
| Rate for Payer: United Healthcare All Other HMO |
$20.44
|
| Rate for Payer: United Healthcare HMO Rider |
$20.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
IP
|
$235.14
|
|
|
Service Code
|
NDC 51144-002-12
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.43 |
| Max. Negotiated Rate |
$199.87 |
| Rate for Payer: Blue Shield of California Commercial |
$167.42
|
| Rate for Payer: Blue Shield of California EPN |
$120.39
|
| Rate for Payer: Cash Price |
$105.81
|
| Rate for Payer: Cigna of CA HMO |
$164.60
|
| Rate for Payer: Cigna of CA PPO |
$164.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.06
|
| Rate for Payer: Galaxy Health WC |
$199.87
|
| Rate for Payer: Global Benefits Group Commercial |
$141.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.43
|
| Rate for Payer: Multiplan Commercial |
$188.11
|
| Rate for Payer: Networks By Design Commercial |
$152.84
|
| Rate for Payer: Prime Health Services Commercial |
$199.87
|
|
|
TUCATINIB 150 MG TABLET [227737]
|
Facility
|
OP
|
$235.14
|
|
|
Service Code
|
NDC 51144-002-12
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.43 |
| Max. Negotiated Rate |
$199.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$154.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$199.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$129.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$129.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.10
|
| Rate for Payer: Blue Distinction Transplant |
$141.08
|
| Rate for Payer: Blue Shield of California Commercial |
$173.30
|
| Rate for Payer: Blue Shield of California EPN |
$137.32
|
| Rate for Payer: Cash Price |
$105.81
|
| Rate for Payer: Cigna of CA HMO |
$164.60
|
| Rate for Payer: Cigna of CA PPO |
$164.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$199.87
|
| Rate for Payer: Dignity Health Media |
$199.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$94.06
|
| Rate for Payer: Galaxy Health WC |
$199.87
|
| Rate for Payer: Global Benefits Group Commercial |
$141.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$176.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$156.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.43
|
| Rate for Payer: Multiplan Commercial |
$188.11
|
| Rate for Payer: Networks By Design Commercial |
$152.84
|
| Rate for Payer: Prime Health Services Commercial |
$199.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$141.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$141.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$117.57
|
| Rate for Payer: United Healthcare All Other HMO |
$117.57
|
| Rate for Payer: United Healthcare HMO Rider |
$117.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$117.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$199.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.87
|
| Rate for Payer: Vantage Medical Group Senior |
$199.87
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
OP
|
$116.94
|
|
|
Service Code
|
NDC 51144-001-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.67
|
| Rate for Payer: Blue Distinction Transplant |
$70.16
|
| Rate for Payer: Blue Shield of California Commercial |
$86.18
|
| Rate for Payer: Blue Shield of California EPN |
$68.29
|
| Rate for Payer: Cash Price |
$52.62
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.40
|
| Rate for Payer: Dignity Health Media |
$99.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.40
|
| Rate for Payer: Global Benefits Group Commercial |
$70.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$87.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.55
|
| Rate for Payer: Networks By Design Commercial |
$76.01
|
| Rate for Payer: Prime Health Services Commercial |
$99.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.47
|
| Rate for Payer: United Healthcare All Other HMO |
$58.47
|
| Rate for Payer: United Healthcare HMO Rider |
$58.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.40
|
| Rate for Payer: Vantage Medical Group Senior |
$99.40
|
|
|
TUCATINIB 50 MG TABLET [227736]
|
Facility
|
IP
|
$116.94
|
|
|
Service Code
|
NDC 51144-001-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.07 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Blue Shield of California Commercial |
$83.26
|
| Rate for Payer: Blue Shield of California EPN |
$59.87
|
| Rate for Payer: Cash Price |
$52.62
|
| Rate for Payer: Cigna of CA HMO |
$81.86
|
| Rate for Payer: Cigna of CA PPO |
$81.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.78
|
| Rate for Payer: Galaxy Health WC |
$99.40
|
| Rate for Payer: Global Benefits Group Commercial |
$70.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.07
|
| Rate for Payer: Multiplan Commercial |
$93.55
|
| Rate for Payer: Networks By Design Commercial |
$76.01
|
| Rate for Payer: Prime Health Services Commercial |
$99.40
|
|
|
Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch
|
Facility
|
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 69610
|
| Min. Negotiated Rate |
$270.92 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Media |
$1,905.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,572.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,905.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,124.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,124.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,086.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,086.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$270.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,905.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,553.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP])
|
Facility
|
OP
|
$13,086.00
|
|
|
Service Code
|
CPT 69633
|
| Min. Negotiated Rate |
$311.24 |
| Max. Negotiated Rate |
$13,086.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13,086.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,241.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,999.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$311.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction
|
Facility
|
OP
|
$13,086.00
|
|
|
Service Code
|
CPT 69631
|
| Min. Negotiated Rate |
$311.24 |
| Max. Negotiated Rate |
$13,086.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$13,086.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,241.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Media |
$7,316.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,999.72
|
| Rate for Payer: Heritage Provider Network Transplant |
$11,999.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$11,853.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$311.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Tympanostomy (requiring insertion of ventilating tube), general anesthesia
|
Facility
|
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 69436
|
| Min. Negotiated Rate |
$229.20 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Media |
$1,905.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,572.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,905.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,124.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,124.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,086.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,086.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$229.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,905.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,553.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
