|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 005
|
| Min. Negotiated Rate |
$203,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$203,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$203,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$203,000.00
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$131,297.18
|
|
|
Service Code
|
APR-DRG 4403
|
| Min. Negotiated Rate |
$104,864.99 |
| Max. Negotiated Rate |
$131,297.18 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$104,864.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$131,297.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$117,476.43
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$339,097.50
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$70,000.00 |
| Max. Negotiated Rate |
$339,097.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$97,905.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$136,556.51
|
| Rate for Payer: EPIC Health Plan Senior |
$91,037.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$339,097.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$70,000.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$82,761.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$115,866.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$110,900.44
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$103,537.33
|
|
|
Service Code
|
APR-DRG 4401
|
| Min. Negotiated Rate |
$82,693.63 |
| Max. Negotiated Rate |
$103,537.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82,693.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$103,537.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$92,638.66
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$255,680.78
|
|
|
Service Code
|
APR-DRG 4404
|
| Min. Negotiated Rate |
$204,208.20 |
| Max. Negotiated Rate |
$255,680.78 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$204,208.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$255,680.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$228,767.01
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$113,329.00
|
|
|
Service Code
|
APR-DRG 4402
|
| Min. Negotiated Rate |
$90,514.08 |
| Max. Negotiated Rate |
$113,329.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$90,514.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$113,329.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$101,399.63
|
|
|
Kidney Transplant - Cadaveric
|
Facility
|
IP
|
$70,887.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$70,887.00 |
| Max. Negotiated Rate |
$70,887.00 |
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal |
$70,887.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70,887.00
|
|
|
Kidney Transplant - Cadaveric
|
Facility
|
IP
|
$70,887.00
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$70,887.00 |
| Max. Negotiated Rate |
$70,887.00 |
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal |
$70,887.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70,887.00
|
|
|
Kidney Transplant - Cadaveric
|
Facility
|
IP
|
$70,887.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$70,887.00 |
| Max. Negotiated Rate |
$70,887.00 |
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal |
$70,887.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$70,887.00
|
|
|
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC
|
Facility
|
IP
|
$162,675.13
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$162,675.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$142,527.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$162,675.13
|
| Rate for Payer: EPIC Health Plan Senior |
$108,450.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$70,000.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$98,590.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$138,027.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$132,111.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC
|
Facility
|
IP
|
$145,008.40
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$7,611.00 |
| Max. Negotiated Rate |
$145,008.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$112,345.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$145,008.40
|
| Rate for Payer: EPIC Health Plan Senior |
$96,672.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Transplant |
$70,000.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$87,883.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123,037.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$117,764.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,844.00
|
| Rate for Payer: United Healthcare All Other HMO |
$10,823.00
|
| Rate for Payer: United Healthcare HMO Rider |
$8,307.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7,611.00
|
|
|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
IP
|
$1,326.00
|
|
|
Service Code
|
HCPCS A9616
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$1,127.10 |
| Rate for Payer: Adventist Health Commercial |
$265.20
|
| Rate for Payer: Blue Shield of California Commercial |
$1,019.69
|
| Rate for Payer: Blue Shield of California Commercial |
$672.28
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$928.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$530.40
|
| Rate for Payer: EPIC Health Plan Senior |
$530.40
|
| Rate for Payer: Galaxy Health WC |
$1,127.10
|
| Rate for Payer: Global Benefits Group Commercial |
$795.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$842.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$782.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.24
|
| Rate for Payer: Multiplan Commercial |
$1,060.80
|
| Rate for Payer: Networks By Design Commercial |
$861.90
|
| Rate for Payer: Prime Health Services Commercial |
$1,127.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$497.65
|
| Rate for Payer: United Healthcare All Other HMO |
$484.39
|
| Rate for Payer: United Healthcare HMO Rider |
$473.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$434.26
|
|
|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
OP
|
$1,326.00
|
|
|
Service Code
|
HCPCS A9616
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$2,823.11 |
| Rate for Payer: Adventist Health Commercial |
$265.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$869.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,288.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,171.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,823.11
|
| Rate for Payer: Blue Shield of California Commercial |
$558.25
|
| Rate for Payer: Blue Shield of California Commercial |
$845.99
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: Cigna of CA HMO |
$848.64
|
| Rate for Payer: Cigna of CA PPO |
$981.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,288.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,171.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$928.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,932.64
|
| Rate for Payer: EPIC Health Plan Senior |
$1,288.43
|
| Rate for Payer: Galaxy Health WC |
$1,127.10
|
| Rate for Payer: Global Benefits Group Commercial |
$795.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,920.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,171.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$842.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,639.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$318.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,475.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,569.54
|
| Rate for Payer: Multiplan Commercial |
$1,060.80
|
| Rate for Payer: Networks By Design Commercial |
$861.90
|
| Rate for Payer: Prime Health Services Commercial |
$1,127.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$795.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$795.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$497.65
|
| Rate for Payer: United Healthcare All Other HMO |
$484.39
|
| Rate for Payer: United Healthcare HMO Rider |
$473.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$434.26
|
| Rate for Payer: Upland Medical Group Pediatric |
$1,171.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,288.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1,171.30
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.93
|
| Rate for Payer: Blue Shield of California Commercial |
$22.97
|
| Rate for Payer: Blue Shield of California Commercial |
$15.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna of CA HMO |
$23.04
|
| Rate for Payer: Cigna of CA PPO |
$26.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$57.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$21.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$21.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.60
|
| Rate for Payer: Vantage Medical Group Senior |
$30.60
|
|
|
KIT FOR PREPARATION OF TC 99M-ALBUMIN 2.5 MG INTRAVENOUS SOLUTION [153474]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A9540
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$27.68
|
| Rate for Payer: Blue Shield of California Commercial |
$18.25
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$25.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.40
|
| Rate for Payer: EPIC Health Plan Senior |
$14.40
|
| Rate for Payer: Galaxy Health WC |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$21.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$22.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.64
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: Networks By Design Commercial |
$23.40
|
| Rate for Payer: Prime Health Services Commercial |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.51
|
| Rate for Payer: United Healthcare All Other HMO |
$13.15
|
| Rate for Payer: United Healthcare HMO Rider |
$12.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.79
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS KIT [153476]
|
Facility
|
OP
|
$2,227.68
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$445.54 |
| Max. Negotiated Rate |
$1,995.97 |
| Rate for Payer: Adventist Health Commercial |
$445.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,225.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,670.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,995.97
|
| Rate for Payer: Blue Shield of California Commercial |
$937.85
|
| Rate for Payer: Blue Shield of California Commercial |
$1,421.26
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: Cigna of CA HMO |
$1,425.72
|
| Rate for Payer: Cigna of CA PPO |
$1,648.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,893.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,893.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,559.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$891.07
|
| Rate for Payer: EPIC Health Plan Senior |
$891.07
|
| Rate for Payer: Galaxy Health WC |
$1,893.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1,336.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$762.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,414.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$862.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,314.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,559.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,559.38
|
| Rate for Payer: Multiplan Commercial |
$1,782.14
|
| Rate for Payer: Networks By Design Commercial |
$1,447.99
|
| Rate for Payer: Prime Health Services Commercial |
$1,893.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,336.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,336.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$836.05
|
| Rate for Payer: United Healthcare All Other HMO |
$813.77
|
| Rate for Payer: United Healthcare HMO Rider |
$796.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$729.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,893.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1,893.53
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS KIT [153476]
|
Facility
|
IP
|
$2,227.68
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$445.54 |
| Max. Negotiated Rate |
$1,893.53 |
| Rate for Payer: Adventist Health Commercial |
$445.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1,713.09
|
| Rate for Payer: Blue Shield of California Commercial |
$1,129.43
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,559.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$891.07
|
| Rate for Payer: EPIC Health Plan Senior |
$891.07
|
| Rate for Payer: Galaxy Health WC |
$1,893.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1,336.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,414.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,314.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$534.64
|
| Rate for Payer: Multiplan Commercial |
$1,782.14
|
| Rate for Payer: Networks By Design Commercial |
$1,447.99
|
| Rate for Payer: Prime Health Services Commercial |
$1,893.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$836.05
|
| Rate for Payer: United Healthcare All Other HMO |
$813.77
|
| Rate for Payer: United Healthcare HMO Rider |
$796.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$729.57
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS SOLUTION [224767]
|
Facility
|
OP
|
$2,056.76
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$411.35 |
| Max. Negotiated Rate |
$2,648.22 |
| Rate for Payer: Adventist Health Commercial |
$411.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,027.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,027.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,648.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1,312.21
|
| Rate for Payer: Blue Shield of California Commercial |
$865.90
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: Cigna of CA HMO |
$1,316.33
|
| Rate for Payer: Cigna of CA PPO |
$1,522.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,027.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,027.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,439.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,541.31
|
| Rate for Payer: EPIC Health Plan Senior |
$1,027.54
|
| Rate for Payer: Galaxy Health WC |
$1,748.25
|
| Rate for Payer: Global Benefits Group Commercial |
$1,234.06
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$1,531.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$934.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,306.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,307.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$493.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,177.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,251.73
|
| Rate for Payer: Multiplan Commercial |
$1,645.41
|
| Rate for Payer: Networks By Design Commercial |
$1,336.89
|
| Rate for Payer: Prime Health Services Commercial |
$1,748.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,234.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,234.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$771.90
|
| Rate for Payer: United Healthcare All Other HMO |
$751.33
|
| Rate for Payer: United Healthcare HMO Rider |
$735.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$673.59
|
| Rate for Payer: Upland Medical Group Pediatric |
$934.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,027.54
|
| Rate for Payer: Vantage Medical Group Senior |
$1,027.54
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS SOLUTION [224767]
|
Facility
|
IP
|
$2,056.76
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$411.35 |
| Max. Negotiated Rate |
$1,748.25 |
| Rate for Payer: Adventist Health Commercial |
$411.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1,042.78
|
| Rate for Payer: Blue Shield of California Commercial |
$1,581.65
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,439.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$822.70
|
| Rate for Payer: EPIC Health Plan Senior |
$822.70
|
| Rate for Payer: Galaxy Health WC |
$1,748.25
|
| Rate for Payer: Global Benefits Group Commercial |
$1,234.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,306.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,213.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$493.62
|
| Rate for Payer: Multiplan Commercial |
$1,645.41
|
| Rate for Payer: Networks By Design Commercial |
$1,336.89
|
| Rate for Payer: Prime Health Services Commercial |
$1,748.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$771.90
|
| Rate for Payer: United Healthcare All Other HMO |
$751.33
|
| Rate for Payer: United Healthcare HMO Rider |
$735.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$673.59
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$345.69 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$345.69
|
| Rate for Payer: Blue Shield of California Commercial |
$9.95
|
| Rate for Payer: Blue Shield of California Commercial |
$6.57
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Cigna of CA HMO |
$9.98
|
| Rate for Payer: Cigna of CA PPO |
$11.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Senior |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$35.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.92
|
| Rate for Payer: Multiplan Commercial |
$12.48
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$13.26
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Blue Shield of California Commercial |
$7.91
|
| Rate for Payer: Blue Shield of California Commercial |
$12.00
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Senior |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.74
|
| Rate for Payer: Multiplan Commercial |
$12.48
|
| Rate for Payer: Networks By Design Commercial |
$10.14
|
| Rate for Payer: Prime Health Services Commercial |
$13.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.70
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.11
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
IP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.18 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.21
|
| Rate for Payer: Blue Shield of California Commercial |
$6.07
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: EPIC Health Plan Senior |
$4.79
|
| Rate for Payer: Galaxy Health WC |
$10.18
|
| Rate for Payer: Global Benefits Group Commercial |
$7.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.58
|
| Rate for Payer: Networks By Design Commercial |
$7.79
|
| Rate for Payer: Prime Health Services Commercial |
$10.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.92
|
|
|
KIT FOR PREPARATION OF TC 99M-SODIUM THIOSULFATE 2 MG SOLUTION [121541]
|
Facility
|
OP
|
$11.98
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$125.85 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$125.85
|
| Rate for Payer: Blue Shield of California Commercial |
$7.64
|
| Rate for Payer: Blue Shield of California Commercial |
$5.04
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna of CA HMO |
$7.67
|
| Rate for Payer: Cigna of CA PPO |
$8.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.79
|
| Rate for Payer: EPIC Health Plan Senior |
$4.79
|
| Rate for Payer: Galaxy Health WC |
$10.18
|
| Rate for Payer: Global Benefits Group Commercial |
$7.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$71.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$80.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.39
|
| Rate for Payer: Multiplan Commercial |
$9.58
|
| Rate for Payer: Networks By Design Commercial |
$7.79
|
| Rate for Payer: Prime Health Services Commercial |
$10.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.18
|
| Rate for Payer: Vantage Medical Group Senior |
$10.18
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
OP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$99.75 |
| Max. Negotiated Rate |
$1,053.90 |
| Rate for Payer: Adventist Health Commercial |
$99.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$423.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,053.90
|
| Rate for Payer: Blue Shield of California Commercial |
$318.22
|
| Rate for Payer: Blue Shield of California Commercial |
$209.98
|
| Rate for Payer: Cash Price |
$224.45
|
| Rate for Payer: Cash Price |
$224.45
|
| Rate for Payer: Cigna of CA HMO |
$319.21
|
| Rate for Payer: Cigna of CA PPO |
$369.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$423.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$423.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$423.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$349.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.51
|
| Rate for Payer: EPIC Health Plan Senior |
$199.51
|
| Rate for Payer: Galaxy Health WC |
$423.95
|
| Rate for Payer: Global Benefits Group Commercial |
$299.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$515.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$316.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$583.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$294.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$349.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$349.14
|
| Rate for Payer: Multiplan Commercial |
$399.02
|
| Rate for Payer: Networks By Design Commercial |
$324.20
|
| Rate for Payer: Prime Health Services Commercial |
$423.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$299.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$299.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$187.19
|
| Rate for Payer: United Healthcare All Other HMO |
$182.20
|
| Rate for Payer: United Healthcare HMO Rider |
$178.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$163.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$423.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$423.95
|
| Rate for Payer: Vantage Medical Group Senior |
$423.95
|
|
