|
Kidney-Heart Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$282,500.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$282,500.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 652
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$258,280.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 005
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$258,280.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 651
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$258,280.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 650
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$258,280.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
Kidney-Liver Transplant
|
Facility
|
IP
|
$285,000.00
|
|
|
Service Code
|
MSDRG 006
|
| Min. Negotiated Rate |
$226,000.00 |
| Max. Negotiated Rate |
$285,000.00 |
| Rate for Payer: Blue Distinction Transplant |
$258,280.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$285,000.00
|
| Rate for Payer: Heritage Provider Network Transplant |
$226,000.00
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$68,588.58
|
|
|
Service Code
|
APR-DRG 4401
|
| Min. Negotiated Rate |
$52,614.66 |
| Max. Negotiated Rate |
$68,588.58 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$52,614.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$59,563.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$68,588.58
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$76,812.10
|
|
|
Service Code
|
APR-DRG 4402
|
| Min. Negotiated Rate |
$58,922.96 |
| Max. Negotiated Rate |
$76,812.10 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$58,922.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$66,705.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$76,812.10
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$135,868.32
|
|
|
Service Code
|
APR-DRG 4404
|
| Min. Negotiated Rate |
$104,225.30 |
| Max. Negotiated Rate |
$135,868.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$104,225.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$117,990.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135,868.32
|
|
|
KIDNEY TRANSPLANT
|
Facility
|
IP
|
$89,559.73
|
|
|
Service Code
|
APR-DRG 4403
|
| Min. Negotiated Rate |
$68,701.74 |
| Max. Negotiated Rate |
$89,559.73 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68,701.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$77,775.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89,559.73
|
|
|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
OP
|
$5,640.00
|
|
|
Service Code
|
CPT A9596
|
| Hospital Charge Code |
ERX233443
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$991.68 |
| Max. Negotiated Rate |
$6,508.93 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6,508.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,239.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,090.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,090.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,003.60
|
| Rate for Payer: Blue Distinction Transplant |
$3,384.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,156.68
|
| Rate for Payer: Blue Shield of California EPN |
$3,293.76
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO |
$3,948.00
|
| Rate for Payer: Cigna of CA PPO |
$3,948.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,239.60
|
| Rate for Payer: Dignity Health Media |
$1,090.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,090.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,338.77
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$991.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$991.68
|
| Rate for Payer: Galaxy Health WC |
$4,794.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,384.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4,230.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,626.36
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,626.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,606.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$1,606.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$991.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,761.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,839.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$991.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,249.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,328.85
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: Networks By Design Commercial |
$2,820.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,794.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3,384.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3,384.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Other HMO |
$2,820.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,820.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,820.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,239.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,090.85
|
| Rate for Payer: Vantage Medical Group Senior |
$1,090.85
|
|
|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
IP
|
$5,640.00
|
|
|
Service Code
|
CPT A9596
|
| Hospital Charge Code |
ERX233443
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,353.60 |
| Max. Negotiated Rate |
$4,794.00 |
| Rate for Payer: Blue Shield of California Commercial |
$4,015.68
|
| Rate for Payer: Blue Shield of California EPN |
$2,887.68
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO |
$3,948.00
|
| Rate for Payer: Cigna of CA PPO |
$3,948.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,256.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,256.00
|
| Rate for Payer: Galaxy Health WC |
$4,794.00
|
| Rate for Payer: Global Benefits Group Commercial |
$3,384.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,761.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,148.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,353.60
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: Networks By Design Commercial |
$2,820.00
|
| Rate for Payer: Prime Health Services Commercial |
$4,794.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,129.66
|
| Rate for Payer: United Healthcare All Other HMO |
$2,080.03
|
| Rate for Payer: United Healthcare HMO Rider |
$2,034.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,861.20
|
|
|
KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
CPT A9503
|
| Hospital Charge Code |
ERX121677
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$288.40 |
| 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 |
$8.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$288.40
|
| Rate for Payer: Blue Distinction Transplant |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$9.22
|
| Rate for Payer: Blue Shield of California EPN |
$7.32
|
| 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 Media |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.85
|
| 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: 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 |
$7.80
|
| Rate for Payer: United Healthcare All Other HMO |
$7.80
|
| Rate for Payer: United Healthcare HMO Rider |
$7.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.80
|
| 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
|
CPT A9503
|
| Hospital Charge Code |
ERX121677
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3.74 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Blue Shield of California Commercial |
$11.11
|
| Rate for Payer: Blue Shield of California EPN |
$7.99
|
| Rate for Payer: Cash Price |
$7.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.24
|
| Rate for Payer: Galaxy Health WC |
$13.26
|
| Rate for Payer: Global Benefits Group Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.94
|
| 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 |
$5.89
|
| Rate for Payer: United Healthcare All Other HMO |
$5.75
|
| Rate for Payer: United Healthcare HMO Rider |
$5.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.15
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
OP
|
$498.77
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
ERX225273
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$119.70 |
| Max. Negotiated Rate |
$879.26 |
| 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 |
$274.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$879.26
|
| Rate for Payer: Blue Distinction Transplant |
$299.26
|
| Rate for Payer: Blue Shield of California Commercial |
$294.77
|
| Rate for Payer: Blue Shield of California EPN |
$233.92
|
| 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 Media |
$423.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$423.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.51
|
| Rate for Payer: EPIC Health Plan Transplant |
$199.51
|
| Rate for Payer: Galaxy Health WC |
$423.95
|
| Rate for Payer: Global Benefits Group Commercial |
$299.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$374.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$583.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.70
|
| 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 |
$249.38
|
| Rate for Payer: United Healthcare All Other HMO |
$249.38
|
| Rate for Payer: United Healthcare HMO Rider |
$249.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.38
|
| 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
|
|
|
KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]
|
Facility
|
IP
|
$498.77
|
|
|
Service Code
|
CPT A9562
|
| Hospital Charge Code |
ERX225273
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$119.70 |
| Max. Negotiated Rate |
$423.95 |
| Rate for Payer: Blue Shield of California Commercial |
$355.12
|
| Rate for Payer: Blue Shield of California EPN |
$255.37
|
| Rate for Payer: Cash Price |
$224.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$199.51
|
| Rate for Payer: Galaxy Health WC |
$423.95
|
| Rate for Payer: Global Benefits Group Commercial |
$299.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$332.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$190.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$119.70
|
| 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: United Healthcare All Other Commercial |
$188.34
|
| Rate for Payer: United Healthcare All Other HMO |
$183.95
|
| Rate for Payer: United Healthcare HMO Rider |
$179.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$164.59
|
|
|
KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
OP
|
$181.13
|
|
|
Service Code
|
CPT A9560
|
| Hospital Charge Code |
ERX225270
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$43.47 |
| Max. Negotiated Rate |
$224.99 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$153.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$99.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$99.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$224.99
|
| Rate for Payer: Blue Distinction Transplant |
$108.68
|
| Rate for Payer: Blue Shield of California Commercial |
$107.05
|
| Rate for Payer: Blue Shield of California EPN |
$84.95
|
| Rate for Payer: Cash Price |
$81.51
|
| Rate for Payer: Cash Price |
$81.51
|
| Rate for Payer: Cigna of CA HMO |
$115.92
|
| Rate for Payer: Cigna of CA PPO |
$134.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.96
|
| Rate for Payer: Dignity Health Media |
$153.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$153.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$72.45
|
| Rate for Payer: Galaxy Health WC |
$153.96
|
| Rate for Payer: Global Benefits Group Commercial |
$108.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$135.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$120.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.47
|
| Rate for Payer: Multiplan Commercial |
$144.90
|
| Rate for Payer: Networks By Design Commercial |
$117.73
|
| Rate for Payer: Prime Health Services Commercial |
$153.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$108.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$108.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.56
|
| Rate for Payer: United Healthcare All Other HMO |
$90.56
|
| Rate for Payer: United Healthcare HMO Rider |
$90.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$90.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$153.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$153.96
|
| Rate for Payer: Vantage Medical Group Senior |
$153.96
|
|
|
KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
IP
|
$181.13
|
|
|
Service Code
|
CPT A9560
|
| Hospital Charge Code |
ERX225270
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$43.47 |
| Max. Negotiated Rate |
$153.96 |
| Rate for Payer: Blue Shield of California Commercial |
$128.96
|
| Rate for Payer: Blue Shield of California EPN |
$92.74
|
| Rate for Payer: Cash Price |
$81.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.45
|
| Rate for Payer: Galaxy Health WC |
$153.96
|
| Rate for Payer: Global Benefits Group Commercial |
$108.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$120.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.47
|
| Rate for Payer: Multiplan Commercial |
$144.90
|
| Rate for Payer: Networks By Design Commercial |
$117.73
|
| Rate for Payer: Prime Health Services Commercial |
$153.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.39
|
| Rate for Payer: United Healthcare All Other HMO |
$66.80
|
| Rate for Payer: United Healthcare HMO Rider |
$65.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$59.77
|
|
|
KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
CPT A9587
|
| Hospital Charge Code |
ERX215477
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$3,060.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,060.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,980.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,980.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.20
|
| Rate for Payer: Blue Distinction Transplant |
$2,160.00
|
| Rate for Payer: Blue Shield of California Commercial |
$2,127.60
|
| Rate for Payer: Blue Shield of California EPN |
$1,688.40
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cigna of CA HMO |
$2,304.00
|
| Rate for Payer: Cigna of CA PPO |
$2,664.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,060.00
|
| Rate for Payer: Dignity Health Media |
$3,060.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,060.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,440.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,440.00
|
| Rate for Payer: Galaxy Health WC |
$3,060.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,160.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,700.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,401.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$864.00
|
| Rate for Payer: Multiplan Commercial |
$2,880.00
|
| Rate for Payer: Networks By Design Commercial |
$2,340.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,060.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2,160.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2,160.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,800.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,800.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,800.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,060.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,060.00
|
| Rate for Payer: Vantage Medical Group Senior |
$3,060.00
|
|
|
KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
CPT A9587
|
| Hospital Charge Code |
ERX215477
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$864.00 |
| Max. Negotiated Rate |
$3,060.00 |
| Rate for Payer: Blue Shield of California Commercial |
$2,563.20
|
| Rate for Payer: Blue Shield of California EPN |
$1,843.20
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,440.00
|
| Rate for Payer: Galaxy Health WC |
$3,060.00
|
| Rate for Payer: Global Benefits Group Commercial |
$2,160.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2,401.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,371.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$864.00
|
| Rate for Payer: Multiplan Commercial |
$2,880.00
|
| Rate for Payer: Networks By Design Commercial |
$2,340.00
|
| Rate for Payer: Prime Health Services Commercial |
$3,060.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,359.36
|
| Rate for Payer: United Healthcare All Other HMO |
$1,327.68
|
| Rate for Payer: United Healthcare HMO Rider |
$1,298.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,188.00
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
ERX121131
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Blue Shield of California Commercial |
$64.08
|
| Rate for Payer: Blue Shield of California EPN |
$46.08
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.00
|
| Rate for Payer: Galaxy Health WC |
$76.50
|
| Rate for Payer: Global Benefits Group Commercial |
$54.00
|
| 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 |
$58.50
|
| Rate for Payer: Prime Health Services Commercial |
$76.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.98
|
| Rate for Payer: United Healthcare All Other HMO |
$33.19
|
| Rate for Payer: United Healthcare HMO Rider |
$32.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.70
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT A9537
|
| Hospital Charge Code |
ERX121131
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$117.51 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$76.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.51
|
| Rate for Payer: Blue Distinction Transplant |
$54.00
|
| Rate for Payer: Blue Shield of California Commercial |
$53.19
|
| Rate for Payer: Blue Shield of California EPN |
$42.21
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna of CA HMO |
$57.60
|
| Rate for Payer: Cigna of CA PPO |
$66.60
|
| 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) Other |
$67.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$60.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.18
|
| 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 |
$58.50
|
| 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
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
OP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$181.40 |
| Max. Negotiated Rate |
$642.45 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$415.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$415.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$482.60
|
| Rate for Payer: Blue Distinction Transplant |
$453.49
|
| Rate for Payer: Blue Shield of California Commercial |
$446.69
|
| Rate for Payer: Blue Shield of California EPN |
$354.48
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: Cigna of CA HMO |
$483.72
|
| Rate for Payer: Cigna of CA PPO |
$559.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$642.45
|
| Rate for Payer: Dignity Health Media |
$642.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$642.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$302.33
|
| Rate for Payer: Galaxy Health WC |
$642.45
|
| Rate for Payer: Global Benefits Group Commercial |
$453.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$566.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.40
|
| Rate for Payer: Multiplan Commercial |
$604.66
|
| Rate for Payer: Networks By Design Commercial |
$491.28
|
| Rate for Payer: Prime Health Services Commercial |
$642.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$453.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$453.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$377.91
|
| Rate for Payer: United Healthcare All Other HMO |
$377.91
|
| Rate for Payer: United Healthcare HMO Rider |
$377.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$377.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$642.45
|
| Rate for Payer: Vantage Medical Group Senior |
$642.45
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
IP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$181.40 |
| Max. Negotiated Rate |
$642.45 |
| Rate for Payer: Blue Shield of California Commercial |
$538.14
|
| Rate for Payer: Blue Shield of California EPN |
$386.98
|
| Rate for Payer: Cash Price |
$340.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$302.33
|
| Rate for Payer: Galaxy Health WC |
$642.45
|
| Rate for Payer: Global Benefits Group Commercial |
$453.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$504.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$287.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$181.40
|
| Rate for Payer: Multiplan Commercial |
$604.66
|
| Rate for Payer: Networks By Design Commercial |
$491.28
|
| Rate for Payer: Prime Health Services Commercial |
$642.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$285.40
|
| Rate for Payer: United Healthcare All Other HMO |
$278.75
|
| Rate for Payer: United Healthcare HMO Rider |
$272.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$249.42
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
|
IP
|
$27,146.34
|
|
|
Service Code
|
APR-DRG 3132
|
| Min. Negotiated Rate |
$20,824.10 |
| Max. Negotiated Rate |
$27,146.34 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,824.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27,146.34
|
|
