|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
|
OP
|
$2,772.36
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$2,079.27 |
| Rate for Payer: Adventist Health Commercial |
$554.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,713.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$101.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$89.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$89.87
|
| Rate for Payer: Blue Shield of California Commercial |
$114.38
|
| Rate for Payer: Blue Shield of California EPN |
$114.38
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,275.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,774.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$80.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,283.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,283.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$80.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,322.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$501.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$93.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$693.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$108.49
|
| Rate for Payer: Multiplan Commercial |
$2,079.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,108.94
|
| Rate for Payer: TriValley Medical Group Senior |
$1,108.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,001.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$917.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.06
|
| Rate for Payer: Vantage Medical Group Senior |
$89.06
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
|
OP
|
$23.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$128.37 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$128.37
|
| Rate for Payer: Blue Shield of California Commercial |
$99.07
|
| Rate for Payer: Blue Shield of California EPN |
$99.07
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$47.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.79
|
| Rate for Payer: Heritage Provider Network Senior |
$10.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$54.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$63.06
|
| Rate for Payer: Multiplan Commercial |
$17.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Vantage Medical Group Senior |
$51.77
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
|
IP
|
$23.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.01
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.79
|
| Rate for Payer: Heritage Provider Network Senior |
$10.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.83
|
| Rate for Payer: Multiplan Commercial |
$17.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.72
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$23.71
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$109.20 |
| Rate for Payer: Adventist Health Commercial |
$4.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$109.20
|
| Rate for Payer: Blue Shield of California Commercial |
$92.33
|
| Rate for Payer: Blue Shield of California EPN |
$92.33
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$56.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$51.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.98
|
| Rate for Payer: Heritage Provider Network Senior |
$10.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$51.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$58.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$68.63
|
| Rate for Payer: Multiplan Commercial |
$17.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.48
|
| Rate for Payer: TriValley Medical Group Senior |
$9.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.34
|
| Rate for Payer: Vantage Medical Group Senior |
$56.34
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$23.71
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$17.78 |
| Rate for Payer: Adventist Health Commercial |
$4.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.27
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.98
|
| Rate for Payer: Heritage Provider Network Senior |
$10.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.93
|
| Rate for Payer: Multiplan Commercial |
$17.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.85
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
OP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$128.37 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$128.37
|
| Rate for Payer: Blue Shield of California Commercial |
$99.07
|
| Rate for Payer: Blue Shield of California EPN |
$99.07
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.46
|
| Rate for Payer: EPIC Health Plan Medicare |
$47.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.40
|
| Rate for Payer: Heritage Provider Network Senior |
$5.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$54.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$63.06
|
| Rate for Payer: Multiplan Commercial |
$8.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.66
|
| Rate for Payer: TriValley Medical Group Senior |
$4.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.86
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Vantage Medical Group Senior |
$51.77
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
IP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.51
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.40
|
| Rate for Payer: Heritage Provider Network Senior |
$5.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.86
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$13.79 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.84
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
OP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$109.20 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$109.20
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$72.29
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.35
|
| Rate for Payer: TriValley Medical Group Senior |
$7.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15777
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
INBORN AND OTHER DISORDERS OF METABOLISM
|
Facility
|
IP
|
$22,538.60
|
|
|
Service Code
|
MSDRG 642
|
| Min. Negotiated Rate |
$16,819.85 |
| Max. Negotiated Rate |
$22,538.60 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,819.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,819.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,342.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,538.60
|
|
|
INC & DRNG,LEG/ANKL;DA OR HTMA
|
Facility
|
OP
|
$7,184.00
|
|
|
Service Code
|
CPT 27603
|
| Hospital Charge Code |
909007603
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,300.30 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Adventist Health Commercial |
$1,436.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,439.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,735.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Cash Price |
$3,232.80
|
| Rate for Payer: Cash Price |
$3,232.80
|
| Rate for Payer: Cash Price |
$3,232.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,669.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,109.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,735.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,735.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,446.90
|
| Rate for Payer: Heritage Provider Network Senior |
$4,595.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,098.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,300.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,296.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,006.17
|
| Rate for Payer: Multiplan Commercial |
$5,388.00
|
| Rate for Payer: Multiplan WC |
$5,794.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,109.55
|
| Rate for Payer: TriValley Medical Group Senior |
$4,109.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Vantage Medical Group Senior |
$3,735.95
|
|
|
INC & DRNG,LEG/ANKL;DA OR HTMA
|
Facility
|
IP
|
$7,184.00
|
|
|
Service Code
|
CPT 27603
|
| Hospital Charge Code |
909007603
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,300.30 |
| Max. Negotiated Rate |
$5,388.00 |
| Rate for Payer: Adventist Health Commercial |
$1,436.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,626.50
|
| Rate for Payer: Cash Price |
$3,232.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,863.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4,863.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,300.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,796.00
|
| Rate for Payer: Multiplan Commercial |
$5,388.00
|
|
|
INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 28002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,068.15 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,068.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,274.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,068.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,068.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,543.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,068.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,929.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,378.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,771.32
|
| Rate for Payer: Multiplan WC |
$3,240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,274.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,274.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,102.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,274.97
|
| Rate for Payer: Vantage Medical Group Senior |
$2,068.15
|
|
|
INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$522.85 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$522.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$784.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$575.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$522.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$522.85
|
| Rate for Payer: Heritage Provider Network Senior |
$643.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$522.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$993.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$601.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$700.62
|
| Rate for Payer: Multiplan WC |
$808.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$575.13
|
| Rate for Payer: TriValley Medical Group Senior |
$575.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$784.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$575.13
|
| Rate for Payer: Vantage Medical Group Senior |
$522.85
|
|
|
INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 10140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,124.23 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,124.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,336.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,124.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,124.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2,612.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,124.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4,036.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,442.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,846.47
|
| Rate for Payer: Multiplan WC |
$3,280.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,336.65
|
| Rate for Payer: TriValley Medical Group Senior |
$2,336.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,186.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,336.65
|
| Rate for Payer: Vantage Medical Group Senior |
$2,124.23
|
|
|
INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 23030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,672.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,735.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,109.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3,735.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,735.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4,595.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,735.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,098.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,296.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,006.17
|
| Rate for Payer: Multiplan WC |
$5,794.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,109.55
|
| Rate for Payer: TriValley Medical Group Senior |
$4,109.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,603.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,109.55
|
| Rate for Payer: Vantage Medical Group Senior |
$3,735.95
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
IP
|
$2,984.99
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$540.28 |
| Max. Negotiated Rate |
$2,238.74 |
| Rate for Payer: Adventist Health Commercial |
$597.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,922.33
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,373.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,611.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,382.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,382.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$540.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$746.25
|
| Rate for Payer: Multiplan Commercial |
$2,238.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,078.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$988.33
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
OP
|
$2,984.99
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.27 |
| Max. Negotiated Rate |
$2,238.74 |
| Rate for Payer: Adventist Health Commercial |
$597.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,844.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.81
|
| Rate for Payer: Blue Shield of California Commercial |
$12.27
|
| Rate for Payer: Blue Shield of California EPN |
$12.27
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Cash Price |
$1,343.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,373.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,910.39
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,382.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1,382.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,423.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$540.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$746.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.30
|
| Rate for Payer: Multiplan Commercial |
$2,238.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,194.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1,194.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,078.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$988.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.20
|
| Rate for Payer: Vantage Medical Group Senior |
$14.20
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.99 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$394.90
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.91
|
| Rate for Payer: Heritage Provider Network Senior |
$283.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.30
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.03
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$378.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.37
|
| Rate for Payer: Blue Shield of California Commercial |
$5.30
|
| Rate for Payer: Blue Shield of California EPN |
$5.30
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.82
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$392.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$5.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$283.91
|
| Rate for Payer: Heritage Provider Network Senior |
$283.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$292.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$110.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$459.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$245.28
|
| Rate for Payer: TriValley Medical Group Senior |
$245.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$221.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$203.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.82
|
| Rate for Payer: Vantage Medical Group Senior |
$5.82
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.82
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.45
|
| Rate for Payer: Heritage Provider Network Senior |
$44.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.79
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$59.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.20
|
| Rate for Payer: Blue Shield of California Commercial |
$58.56
|
| Rate for Payer: Blue Shield of California EPN |
$46.85
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$9.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.45
|
| Rate for Payer: Heritage Provider Network Senior |
$44.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$45.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$38.40
|
| Rate for Payer: TriValley Medical Group Senior |
$38.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.23
|
| Rate for Payer: Vantage Medical Group Senior |
$9.30
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
IP
|
$4,608.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$834.05 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,967.55
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,488.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,119.62
|
| Rate for Payer: Heritage Provider Network Senior |
$3,119.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$834.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,152.00
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,664.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,525.71
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
|
Facility
|
OP
|
$4,608.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$834.05 |
| Max. Negotiated Rate |
$21,835.83 |
| Rate for Payer: Adventist Health Commercial |
$921.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,501.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,201.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,201.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21,835.83
|
| Rate for Payer: Blue Shield of California Commercial |
$2,810.88
|
| Rate for Payer: Blue Shield of California EPN |
$2,248.70
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,995.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,501.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,201.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,201.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,949.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,000.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,852.35
|
| Rate for Payer: Heritage Provider Network Senior |
$2,852.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,000.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,198.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$834.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2,301.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,152.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2,681.26
|
| Rate for Payer: Multiplan Commercial |
$3,456.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,201.03
|
| Rate for Payer: TriValley Medical Group Senior |
$2,000.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,664.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,525.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,501.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,201.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2,201.03
|
|
