|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
ERX199666
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.63
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$7.06
|
| Rate for Payer: Blue Shield of California EPN |
$5.49
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: IEHP medi-cal |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Riverside University Health MISP |
$4.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.63
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$7.06
|
| Rate for Payer: Blue Shield of California EPN |
$5.49
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: IEHP medi-cal |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Riverside University Health MISP |
$4.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.63
|
| Rate for Payer: BCBS Transplant Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$7.06
|
| Rate for Payer: Blue Shield of California EPN |
$5.49
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: IEHP medi-cal |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: Riverside University Health MISP |
$4.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.61
|
| Rate for Payer: United Healthcare All Other HMO |
$5.61
|
| Rate for Payer: United Healthcare HMO Rider |
$5.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Blue Shield of California Commercial |
$8.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.99
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Blue Shield of California Commercial |
$8.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.99
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.54
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.24
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.29
|
| Rate for Payer: Prime Health Services Commercial |
$9.54
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$15,667.44
|
|
|
Service Code
|
APR-DRG 2332
|
| Min. Negotiated Rate |
$13,147.50 |
| Max. Negotiated Rate |
$15,667.44 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,147.50
|
| Rate for Payer: IEHP medi-cal |
$15,667.44
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$22,704.30
|
|
|
Service Code
|
APR-DRG 2333
|
| Min. Negotiated Rate |
$19,052.56 |
| Max. Negotiated Rate |
$22,704.30 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,052.56
|
| Rate for Payer: IEHP medi-cal |
$22,704.30
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$12,131.65
|
|
|
Service Code
|
APR-DRG 2331
|
| Min. Negotiated Rate |
$10,180.40 |
| Max. Negotiated Rate |
$12,131.65 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,180.40
|
| Rate for Payer: IEHP medi-cal |
$12,131.65
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$33,964.36
|
|
|
Service Code
|
APR-DRG 2334
|
| Min. Negotiated Rate |
$28,501.56 |
| Max. Negotiated Rate |
$33,964.36 |
| Rate for Payer: Adventist Health Medi-Cal |
$28,501.56
|
| Rate for Payer: IEHP medi-cal |
$33,964.36
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$12,706.94
|
|
|
Service Code
|
APR-DRG 2342
|
| Min. Negotiated Rate |
$10,663.16 |
| Max. Negotiated Rate |
$12,706.94 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,663.16
|
| Rate for Payer: IEHP medi-cal |
$12,706.94
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$18,682.66
|
|
|
Service Code
|
APR-DRG 2343
|
| Min. Negotiated Rate |
$15,677.76 |
| Max. Negotiated Rate |
$18,682.66 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,677.76
|
| Rate for Payer: IEHP medi-cal |
$18,682.66
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$31,816.73
|
|
|
Service Code
|
APR-DRG 2344
|
| Min. Negotiated Rate |
$26,699.35 |
| Max. Negotiated Rate |
$31,816.73 |
| Rate for Payer: Adventist Health Medi-Cal |
$26,699.35
|
| Rate for Payer: IEHP medi-cal |
$31,816.73
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$9,838.53
|
|
|
Service Code
|
APR-DRG 2341
|
| Min. Negotiated Rate |
$8,256.11 |
| Max. Negotiated Rate |
$9,838.53 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,256.11
|
| Rate for Payer: IEHP medi-cal |
$9,838.53
|
|
|
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
|
Facility
OP
|
$27,132.55
|
|
|
Service Code
|
CPT 20692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$27,132.55 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,443.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16,443.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$22,481.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$16,443.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24,665.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,199.36
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$16,443.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$16,443.97
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$26,968.11
|
| Rate for Payer: IEHP medi-cal |
$27,132.55
|
| Rate for Payer: IEHP Medicare Advantage |
$16,443.97
|
| Rate for Payer: Innovage PACE Commercial |
$24,665.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16,443.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22,034.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22,034.92
|
| Rate for Payer: Multiplan WC |
$22,481.26
|
| Rate for Payer: Preferred Health Network WC |
$22,940.06
|
| Rate for Payer: Prime Health Services Medicare |
$17,430.61
|
| Rate for Payer: Prime Health Services WC |
$22,251.86
|
| Rate for Payer: Riverside University Health MISP |
$18,088.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16,443.97
|
|
|
Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 20690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,938.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$12,220.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$8,938.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,067.02
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$8,938.53
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$14,659.19
|
| Rate for Payer: IEHP medi-cal |
$14,748.57
|
| Rate for Payer: IEHP Medicare Advantage |
$8,938.53
|
| Rate for Payer: Innovage PACE Commercial |
$13,407.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,938.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,977.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,977.63
|
| Rate for Payer: Multiplan WC |
$12,220.24
|
| Rate for Payer: Preferred Health Network WC |
$12,469.63
|
| Rate for Payer: Prime Health Services Medicare |
$9,474.84
|
| Rate for Payer: Prime Health Services WC |
$12,095.54
|
| Rate for Payer: Riverside University Health MISP |
$9,832.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
|
Facility
OP
|
$7,027.00
|
|
|
Service Code
|
CPT 21110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.44 |
| Max. Negotiated Rate |
$7,027.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$1,905.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: Caremore Medicare Advantage |
$1,905.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,572.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,905.44
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,124.92
|
| Rate for Payer: IEHP medi-cal |
$3,143.98
|
| Rate for Payer: IEHP Medicare Advantage |
$1,905.44
|
| Rate for Payer: Innovage PACE Commercial |
$2,858.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,905.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,553.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,553.29
|
| Rate for Payer: Prime Health Services Medicare |
$2,019.77
|
| Rate for Payer: Riverside University Health MISP |
$2,095.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 15276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$683.14 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$951.13
|
| Rate for Payer: Blue Shield of California EPN |
$683.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 15272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$683.14 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$951.13
|
| Rate for Payer: Blue Shield of California EPN |
$683.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,278.49 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$2,278.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$2,278.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,075.96
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,278.49
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$3,736.72
|
| Rate for Payer: IEHP medi-cal |
$3,759.51
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Innovage PACE Commercial |
$3,417.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,278.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,053.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,053.18
|
| Rate for Payer: Prime Health Services Medicare |
$2,415.20
|
| Rate for Payer: Riverside University Health MISP |
$2,506.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,893.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7,027.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,217.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.11
|
| Rate for Payer: BCBS Transplant Transplant |
$9.25
|
| Rate for Payer: Blue Shield of California Commercial |
$9.70
|
| Rate for Payer: Blue Shield of California EPN |
$7.54
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.56
|
| Rate for Payer: IEHP medi-cal |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: Riverside University Health MISP |
$6.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.71
|
| Rate for Payer: United Healthcare All Other HMO |
$7.71
|
| Rate for Payer: United Healthcare HMO Rider |
$7.71
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
IP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$13.88 |
| Rate for Payer: Blue Shield of California Commercial |
$11.56
|
| Rate for Payer: Blue Shield of California EPN |
$8.23
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Central Health Plan Commercial |
$12.34
|
| Rate for Payer: Cigna of CA HMO |
$10.79
|
| Rate for Payer: Cigna of CA PPO |
$10.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.17
|
| Rate for Payer: Galaxy Health WC |
$13.11
|
| Rate for Payer: Global Benefits Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.08
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Networks By Design Commercial |
$10.02
|
| Rate for Payer: Prime Health Services Commercial |
$13.11
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Adventist Health Medi-Cal |
$1.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.34
|
| Rate for Payer: BCBS Transplant Transplant |
$16.80
|
| Rate for Payer: Blue Shield of California Commercial |
$3.91
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Caremore Medicare Advantage |
$1.73
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Central Health Plan Commercial |
$22.40
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$21.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$2.84
|
| Rate for Payer: IEHP medi-cal |
$2.85
|
| Rate for Payer: IEHP Medicare Advantage |
$1.73
|
| Rate for Payer: Innovage PACE Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.32
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
| Rate for Payer: Prime Health Services Medicare |
$1.83
|
| Rate for Payer: Riverside University Health MISP |
$1.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.00
|
| Rate for Payer: United Healthcare All Other HMO |
$14.00
|
| Rate for Payer: United Healthcare HMO Rider |
$14.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Vantage Medical Group Senior |
$1.73
|
|
|
APREPITANT 7.2 MG/ML INTRAVENOUS EMULSION [220348]
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
CPT J0185
|
| Hospital Charge Code |
NDG220348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Blue Shield of California Commercial |
$21.00
|
| Rate for Payer: Blue Shield of California EPN |
$14.95
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Central Health Plan Commercial |
$22.40
|
| Rate for Payer: Cigna of CA HMO |
$19.60
|
| Rate for Payer: Cigna of CA PPO |
$19.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.20
|
| Rate for Payer: Galaxy Health WC |
$23.80
|
| Rate for Payer: Global Benefits Group Commercial |
$16.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$14.00
|
| Rate for Payer: Prime Health Services Commercial |
$23.80
|
|
|
Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 66180
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,755.97 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$5,080.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11,071.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5,080.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,621.66
|
| Rate for Payer: Blue Shield of California EPN |
$4,755.97
|
| Rate for Payer: Caremore Medicare Advantage |
$5,080.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7,620.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,858.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5,080.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,080.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$8,331.20
|
| Rate for Payer: IEHP medi-cal |
$8,382.00
|
| Rate for Payer: IEHP Medicare Advantage |
$5,080.00
|
| Rate for Payer: Innovage PACE Commercial |
$7,620.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,080.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,807.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,807.20
|
| Rate for Payer: Prime Health Services Medicare |
$5,384.80
|
| Rate for Payer: Riverside University Health MISP |
$5,588.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7,620.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,588.00
|
| Rate for Payer: Vantage Medical Group Senior |
$5,080.00
|
|
