|
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 |
$6.52 |
| Max. Negotiated Rate |
$48.60 |
| 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: Blue Shield of California Commercial |
$21.96
|
| Rate for Payer: Blue Shield of California EPN |
$17.57
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Senior |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| 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 |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.92
|
| 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 |
$6.52 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.92
|
|
|
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 |
$2.82 |
| Max. Negotiated Rate |
$30.57 |
| 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: Blue Shield of California Commercial |
$9.52
|
| Rate for Payer: Blue Shield of California EPN |
$7.61
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$13.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Senior |
$9.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| 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 |
$11.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.17
|
| 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 |
$2.82 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Cash Price |
$8.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.56
|
| Rate for Payer: Heritage Provider Network Senior |
$10.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$11.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.17
|
|
|
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 |
$2.17 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.11
|
| Rate for Payer: Heritage Provider Network Senior |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$8.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.97
|
|
|
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 |
$2.17 |
| Max. Negotiated Rate |
$68.95 |
| 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: Blue Shield of California Commercial |
$7.31
|
| Rate for Payer: Blue Shield of California EPN |
$5.85
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.18
|
| Rate for Payer: Dignity Health Senior |
$10.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.42
|
| Rate for Payer: Heritage Provider Network Senior |
$7.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| 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 |
$8.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.97
|
| 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
|
IP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$90.28 |
| Max. Negotiated Rate |
$374.08 |
| Rate for Payer: Adventist Health Commercial |
$99.75
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.67
|
| Rate for Payer: Heritage Provider Network Senior |
$337.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.69
|
| Rate for Payer: Multiplan Commercial |
$374.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$165.14
|
|
|
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 |
$90.28 |
| Max. Negotiated Rate |
$497.31 |
| 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: Blue Shield of California Commercial |
$304.25
|
| Rate for Payer: Blue Shield of California EPN |
$243.40
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Cash Price |
$274.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$423.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$423.95
|
| Rate for Payer: Dignity Health Senior |
$423.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.74
|
| Rate for Payer: Heritage Provider Network Senior |
$308.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$497.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$237.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.69
|
| 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 |
$374.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$165.14
|
| 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 TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
IP
|
$181.13
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$135.85 |
| Rate for Payer: Adventist Health Commercial |
$36.23
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$122.63
|
| Rate for Payer: Heritage Provider Network Senior |
$122.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.28
|
| Rate for Payer: Multiplan Commercial |
$135.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.97
|
|
|
KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]
|
Facility
|
OP
|
$181.13
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$153.96 |
| Rate for Payer: Adventist Health Commercial |
$36.23
|
| 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 |
$135.85
|
| Rate for Payer: Blue Shield of California Commercial |
$110.49
|
| Rate for Payer: Blue Shield of California EPN |
$88.39
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: Cash Price |
$99.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$153.96
|
| Rate for Payer: Dignity Health Senior |
$153.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$115.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$112.12
|
| Rate for Payer: Heritage Provider Network Senior |
$112.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$83.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$86.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$126.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$126.79
|
| Rate for Payer: Multiplan Commercial |
$135.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$65.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.97
|
| 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 THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.93
|
| Rate for Payer: Heritage Provider Network Senior |
$60.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.80
|
|
|
KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Adventist Health Commercial |
$18.00
|
| 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 |
$67.50
|
| Rate for Payer: Blue Shield of California Commercial |
$54.90
|
| Rate for Payer: Blue Shield of California EPN |
$43.92
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.50
|
| Rate for Payer: Dignity Health Senior |
$76.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.71
|
| Rate for Payer: Heritage Provider Network Senior |
$55.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$73.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$63.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$32.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.80
|
| 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 PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]
|
Facility
|
OP
|
$818.62
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$148.17 |
| Max. Negotiated Rate |
$695.83 |
| Rate for Payer: Adventist Health Commercial |
$163.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$695.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$450.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$613.97
|
| Rate for Payer: Blue Shield of California Commercial |
$499.36
|
| Rate for Payer: Blue Shield of California EPN |
$399.49
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$532.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$695.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$695.83
|
| Rate for Payer: Dignity Health Senior |
$695.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$506.73
|
| Rate for Payer: Heritage Provider Network Senior |
$506.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$156.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$390.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$573.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$573.03
|
| Rate for Payer: Multiplan Commercial |
$613.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$295.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$695.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$695.83
|
| Rate for Payer: Vantage Medical Group Senior |
$695.83
|
|
|
KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]
|
Facility
|
IP
|
$818.62
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$148.17 |
| Max. Negotiated Rate |
$613.97 |
| Rate for Payer: Adventist Health Commercial |
$163.72
|
| Rate for Payer: Cash Price |
$450.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$442.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$554.21
|
| Rate for Payer: Heritage Provider Network Senior |
$554.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$148.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$204.66
|
| Rate for Payer: Multiplan Commercial |
$613.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$295.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$271.05
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
IP
|
$755.82
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$566.87 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Cash Price |
$415.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$408.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$511.69
|
| Rate for Payer: Heritage Provider Network Senior |
$511.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Multiplan Commercial |
$566.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$273.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$250.25
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
|
OP
|
$755.82
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$642.45 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| 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 |
$566.87
|
| Rate for Payer: Blue Shield of California Commercial |
$461.05
|
| Rate for Payer: Blue Shield of California EPN |
$368.84
|
| Rate for Payer: Cash Price |
$415.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$491.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$642.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$642.45
|
| Rate for Payer: Dignity Health Senior |
$642.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$483.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$467.85
|
| Rate for Payer: Heritage Provider Network Senior |
$467.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$360.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$529.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$529.07
|
| Rate for Payer: Multiplan Commercial |
$566.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$273.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$250.25
|
| 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 PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$157.72 |
| 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: Blue Shield of California Commercial |
$21.96
|
| Rate for Payer: Blue Shield of California EPN |
$17.57
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.60
|
| Rate for Payer: Dignity Health Senior |
$30.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.28
|
| Rate for Payer: Heritage Provider Network Senior |
$22.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$157.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| 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 |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.92
|
| 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 PREPARATION OF TC 99M-SESTAMIBI COMBO NO.1 IV SOLUTION [121547]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.37
|
| Rate for Payer: Heritage Provider Network Senior |
$24.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.92
|
|
|
KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]
|
Facility
|
IP
|
$28.62
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$21.46 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.38
|
| Rate for Payer: Heritage Provider Network Senior |
$19.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.48
|
|
|
KIT PREPARATION OF TC-99M-SODIUM PYROPHOSPHATE 12 MG IV SOLUTION [121139]
|
Facility
|
OP
|
$28.62
|
|
|
Service Code
|
HCPCS A9538
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$103.76 |
| Rate for Payer: Adventist Health Commercial |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.46
|
| Rate for Payer: Blue Shield of California Commercial |
$17.46
|
| Rate for Payer: Blue Shield of California EPN |
$13.97
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: Cash Price |
$15.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.33
|
| Rate for Payer: Dignity Health Senior |
$24.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Senior |
$17.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$103.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.03
|
| Rate for Payer: Multiplan Commercial |
$21.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.33
|
| Rate for Payer: Vantage Medical Group Senior |
$24.33
|
|
|
Knee Implant (must be billed with Knee Surgery ICD-10-PCS)
|
Facility
|
IP
|
$7,663.00
|
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$7,663.00 |
| Max. Negotiated Rate |
$7,663.00 |
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,663.00
|
|
|
Knee Implant (must be billed with Knee Surgery ICD-10-PCS)
|
Facility
|
IP
|
$7,663.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,663.00 |
| Max. Negotiated Rate |
$7,663.00 |
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,663.00
|
|
|
Knee Implant (must be billed with Knee Surgery ICD-10-PCS)
|
Facility
|
IP
|
$6,247.00
|
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$6,247.00 |
| Max. Negotiated Rate |
$6,247.00 |
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,247.00
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
K-PHOS NEUTRAL ORAL SUSP CMPD 25 MG/ML (0.1 MEQ/ML) [4080284]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 9994-0802-84
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
