|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 60687-476-11
|
| Hospital Charge Code |
1710103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: BCBS Transplant Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Media |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
IP
|
$0.55
|
|
|
Service Code
|
NDC 60687-476-01
|
| Hospital Charge Code |
1710103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
IP
|
$0.55
|
|
|
Service Code
|
NDC 60687-476-11
|
| Hospital Charge Code |
1710103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 16729-226-01
|
| Hospital Charge Code |
1710103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 16729-226-01
|
| Hospital Charge Code |
1710103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: BCBS Transplant Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SPIRONOLACTONE/HCTZ ORAL SUSP COMPOUND 5 MG/ML [4080340]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0803-40
|
| Hospital Charge Code |
1715090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
SPIRONOLACTONE/HCTZ ORAL SUSP COMPOUND 5 MG/ML [4080340]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994-0803-40
|
| Hospital Charge Code |
1715090
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
SPIRONOLACTONE ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080339]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-39
|
| Hospital Charge Code |
1715003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: BCBS Transplant Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SPIRONOLACTONE ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080339]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-39
|
| Hospital Charge Code |
1715003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
SPLENECTOMY
|
Facility
IP
|
$41,999.08
|
|
|
Service Code
|
APR-DRG 6503
|
| Min. Negotiated Rate |
$32,217.72 |
| Max. Negotiated Rate |
$41,999.08 |
| Rate for Payer: IEHP Medi-Cal |
$32,217.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,999.08
|
|
|
SPLENECTOMY
|
Facility
IP
|
$68,670.14
|
|
|
Service Code
|
APR-DRG 6504
|
| Min. Negotiated Rate |
$52,677.23 |
| Max. Negotiated Rate |
$68,670.14 |
| Rate for Payer: IEHP Medi-Cal |
$52,677.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68,670.14
|
|
|
SPLENECTOMY
|
Facility
IP
|
$21,535.13
|
|
|
Service Code
|
APR-DRG 6501
|
| Min. Negotiated Rate |
$16,519.71 |
| Max. Negotiated Rate |
$21,535.13 |
| Rate for Payer: IEHP Medi-Cal |
$16,519.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,535.13
|
|
|
SPLENECTOMY
|
Facility
IP
|
$28,501.27
|
|
|
Service Code
|
APR-DRG 6502
|
| Min. Negotiated Rate |
$21,863.48 |
| Max. Negotiated Rate |
$28,501.27 |
| Rate for Payer: IEHP Medi-Cal |
$21,863.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,501.27
|
|
|
Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)
|
Facility
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 61782
|
| Min. Negotiated Rate |
$61.35 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.35
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
IP
|
$190.80
|
|
|
Service Code
|
NDC 62327-444-44
|
| Hospital Charge Code |
ERX221295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.79 |
| Max. Negotiated Rate |
$162.18 |
| Rate for Payer: Blue Shield of California Commercial |
$135.85
|
| Rate for Payer: Blue Shield of California EPN |
$97.69
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.79
|
| Rate for Payer: Multiplan Commercial |
$152.64
|
| Rate for Payer: Networks By Design Commercial |
$124.02
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
OP
|
$190.80
|
|
|
Service Code
|
NDC 62327-444-44
|
| Hospital Charge Code |
ERX221295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.79 |
| Max. Negotiated Rate |
$162.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$125.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$104.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$104.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.68
|
| Rate for Payer: BCBS Transplant Transplant |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$140.62
|
| Rate for Payer: Blue Shield of California EPN |
$111.43
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cigna of CA HMO |
$122.11
|
| Rate for Payer: Cigna of CA PPO |
$141.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.18
|
| Rate for Payer: Dignity Health Media |
$162.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.32
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$143.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.79
|
| Rate for Payer: Multiplan Commercial |
$152.64
|
| Rate for Payer: Networks By Design Commercial |
$124.02
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.40
|
| Rate for Payer: United Healthcare All Other HMO |
$95.40
|
| Rate for Payer: United Healthcare HMO Rider |
$95.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.18
|
| Rate for Payer: Vantage Medical Group Senior |
$162.18
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
OP
|
$190.80
|
|
|
Service Code
|
NDC 62327-444-04
|
| Hospital Charge Code |
ERX221295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.79 |
| Max. Negotiated Rate |
$162.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$125.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$162.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$104.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$104.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.68
|
| Rate for Payer: BCBS Transplant Transplant |
$114.48
|
| Rate for Payer: Blue Shield of California Commercial |
$140.62
|
| Rate for Payer: Blue Shield of California EPN |
$111.43
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cigna of CA HMO |
$122.11
|
| Rate for Payer: Cigna of CA PPO |
$141.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$162.18
|
| Rate for Payer: Dignity Health Media |
$162.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$162.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.32
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$143.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.79
|
| Rate for Payer: Multiplan Commercial |
$152.64
|
| Rate for Payer: Networks By Design Commercial |
$124.02
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.40
|
| Rate for Payer: United Healthcare All Other HMO |
$95.40
|
| Rate for Payer: United Healthcare HMO Rider |
$95.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$162.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$162.18
|
| Rate for Payer: Vantage Medical Group Senior |
$162.18
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
IP
|
$190.80
|
|
|
Service Code
|
NDC 62327-444-04
|
| Hospital Charge Code |
ERX221295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.79 |
| Max. Negotiated Rate |
$162.18 |
| Rate for Payer: Blue Shield of California Commercial |
$135.85
|
| Rate for Payer: Blue Shield of California EPN |
$97.69
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.79
|
| Rate for Payer: Multiplan Commercial |
$152.64
|
| Rate for Payer: Networks By Design Commercial |
$124.02
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
|
|
STERILE TALC 5 GRAM INTRAPLEURAL SUSPENSION [37812]
|
Facility
OP
|
$119.40
|
|
|
Service Code
|
NDC 63256-200-05
|
| Hospital Charge Code |
1756020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$101.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$78.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$101.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$65.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$71.14
|
| Rate for Payer: BCBS Transplant Transplant |
$71.64
|
| Rate for Payer: Blue Shield of California Commercial |
$88.00
|
| Rate for Payer: Blue Shield of California EPN |
$69.73
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Cigna of CA HMO |
$76.42
|
| Rate for Payer: Cigna of CA PPO |
$88.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.49
|
| Rate for Payer: Dignity Health Media |
$101.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$101.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$47.76
|
| Rate for Payer: Galaxy Health WC |
$101.49
|
| Rate for Payer: Global Benefits Group Commercial |
$71.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$89.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$79.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.66
|
| Rate for Payer: Multiplan Commercial |
$95.52
|
| Rate for Payer: Networks By Design Commercial |
$77.61
|
| Rate for Payer: Prime Health Services Commercial |
$101.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$71.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$71.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$59.70
|
| Rate for Payer: United Healthcare All Other HMO |
$59.70
|
| Rate for Payer: United Healthcare HMO Rider |
$59.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$59.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$101.49
|
| Rate for Payer: Vantage Medical Group Senior |
$101.49
|
|
|
STERILE TALC 5 GRAM INTRAPLEURAL SUSPENSION [37812]
|
Facility
IP
|
$119.40
|
|
|
Service Code
|
NDC 63256-200-05
|
| Hospital Charge Code |
1756020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$101.49 |
| Rate for Payer: Blue Shield of California Commercial |
$85.01
|
| Rate for Payer: Blue Shield of California EPN |
$61.13
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.76
|
| Rate for Payer: Galaxy Health WC |
$101.49
|
| Rate for Payer: Global Benefits Group Commercial |
$71.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$79.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.66
|
| Rate for Payer: Multiplan Commercial |
$95.52
|
| Rate for Payer: Networks By Design Commercial |
$77.61
|
| Rate for Payer: Prime Health Services Commercial |
$101.49
|
|
|
Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure)
|
Facility
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 67334
|
| Min. Negotiated Rate |
$132.28 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$132.28
|
|
|
Strabismus surgery, recession or resection procedure; 1 horizontal muscle
|
Facility
OP
|
$9,590.00
|
|
|
Service Code
|
CPT 67311
|
| Min. Negotiated Rate |
$198.06 |
| Max. Negotiated Rate |
$9,590.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9,590.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,282.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Media |
$2,919.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,941.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,919.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,788.26
|
| Rate for Payer: Heritage Provider Network Transplant |
$4,788.26
|
| Rate for Payer: IEHP Medi-Cal |
$4,729.87
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$4,729.87
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$198.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,919.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,912.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior oblique)
|
Facility
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 67314
|
| Min. Negotiated Rate |
$2,919.67 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Media |
$2,919.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,941.55
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,919.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,788.26
|
| Rate for Payer: Heritage Provider Network Transplant |
$4,788.26
|
| Rate for Payer: IEHP Medi-Cal |
$4,729.87
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$4,729.87
|
| Rate for Payer: IEHP Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,919.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,912.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Strabismus surgery, recession or resection procedure; 2 horizontal muscles
|
Facility
OP
|
$12,491.00
|
|
|
Service Code
|
CPT 67312
|
| Min. Negotiated Rate |
$990.32 |
| Max. Negotiated Rate |
$12,491.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12,491.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,830.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,049.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Dignity Health Media |
$4,830.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,313.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,521.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,830.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,830.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$7,922.50
|
| Rate for Payer: Heritage Provider Network Transplant |
$7,922.50
|
| Rate for Payer: IEHP Medi-Cal |
$7,825.88
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$7,825.88
|
| Rate for Payer: IEHP Medicare Advantage |
$4,830.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$990.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,830.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,086.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,473.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,246.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,313.87
|
| Rate for Payer: Vantage Medical Group Senior |
$4,830.79
|
|
|
STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION [7508]
|
Facility
OP
|
$90.00
|
|
|
Service Code
|
CPT J3000
|
| Hospital Charge Code |
1720358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$204.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$204.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$49.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.47
|
| Rate for Payer: BCBS Transplant Transplant |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$66.33
|
| Rate for Payer: Blue Shield of California EPN |
$93.75
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO |
$63.00
|
| Rate for Payer: Cigna of CA PPO |
$63.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Media |
$76.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$36.00
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$67.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.60
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: Networks By Design Commercial |
$45.00
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$54.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$54.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.00
|
| Rate for Payer: United Healthcare All Other HMO |
$45.00
|
| Rate for Payer: United Healthcare HMO Rider |
$45.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.50
|
| Rate for Payer: Vantage Medical Group Senior |
$76.50
|
|
