|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
OP
|
$1,326.00
|
|
|
Service Code
|
HCPCS A9616
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$240.01 |
| Max. Negotiated Rate |
$2,678.71 |
| Rate for Payer: Adventist Health Commercial |
$265.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$819.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,288.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,171.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,678.71
|
| Rate for Payer: Blue Shield of California Commercial |
$808.86
|
| Rate for Payer: Blue Shield of California EPN |
$647.09
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$861.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,288.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,171.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$848.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,171.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$820.79
|
| Rate for Payer: Heritage Provider Network Senior |
$820.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,171.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$632.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$240.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,346.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$331.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,569.54
|
| Rate for Payer: Multiplan Commercial |
$994.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,288.43
|
| Rate for Payer: TriValley Medical Group Senior |
$1,171.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$479.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$439.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,756.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,288.43
|
| Rate for Payer: Vantage Medical Group Senior |
$1,171.30
|
|
|
KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]
|
Facility
|
IP
|
$1,326.00
|
|
|
Service Code
|
HCPCS A9616
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$240.01 |
| Max. Negotiated Rate |
$994.50 |
| Rate for Payer: Adventist Health Commercial |
$265.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$853.94
|
| Rate for Payer: Cash Price |
$596.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$716.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$897.70
|
| Rate for Payer: Heritage Provider Network Senior |
$897.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$240.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$331.50
|
| Rate for Payer: Multiplan Commercial |
$994.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$479.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$439.04
|
|
|
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 |
$48.33 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.33
|
| 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 |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$23.18
|
| Rate for Payer: Cash Price |
$16.20
|
| 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 Foundation Hospitals 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-EXAMETAZIME 0.5 MG INTRAVENOUS KIT [153476]
|
Facility
|
OP
|
$2,227.68
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$403.21 |
| Max. Negotiated Rate |
$1,893.88 |
| Rate for Payer: Adventist Health Commercial |
$445.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,225.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,670.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,893.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,358.88
|
| Rate for Payer: Blue Shield of California EPN |
$1,087.11
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,447.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,893.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,893.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,425.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,378.93
|
| Rate for Payer: Heritage Provider Network Senior |
$1,378.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,062.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$403.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$556.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,559.38
|
| Rate for Payer: Multiplan Commercial |
$1,670.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$804.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$737.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,893.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,893.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1,893.53
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS KIT [153476]
|
Facility
|
IP
|
$2,227.68
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$403.21 |
| Max. Negotiated Rate |
$1,670.76 |
| Rate for Payer: Adventist Health Commercial |
$445.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,434.63
|
| Rate for Payer: Cash Price |
$1,002.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,202.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,508.14
|
| Rate for Payer: Heritage Provider Network Senior |
$1,508.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$403.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$556.92
|
| Rate for Payer: Multiplan Commercial |
$1,670.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$804.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$737.58
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS SOLUTION [224767]
|
Facility
|
IP
|
$2,056.76
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$372.27 |
| Max. Negotiated Rate |
$1,542.57 |
| Rate for Payer: Adventist Health Commercial |
$411.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,324.55
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,110.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,392.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1,392.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$372.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.19
|
| Rate for Payer: Multiplan Commercial |
$1,542.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$743.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$680.99
|
|
|
KIT FOR PREPARATION OF TC-99M-EXAMETAZIME 0.5 MG INTRAVENOUS SOLUTION [224767]
|
Facility
|
OP
|
$2,056.76
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$372.27 |
| Max. Negotiated Rate |
$2,512.76 |
| Rate for Payer: Adventist Health Commercial |
$411.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,027.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,027.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,512.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1,254.62
|
| Rate for Payer: Blue Shield of California EPN |
$1,003.70
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: Cash Price |
$925.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,336.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,027.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,027.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,316.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$934.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,273.13
|
| Rate for Payer: Heritage Provider Network Senior |
$1,273.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$934.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$981.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$372.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,074.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$514.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,251.73
|
| Rate for Payer: Multiplan Commercial |
$1,542.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,027.54
|
| Rate for Payer: TriValley Medical Group Senior |
$934.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$743.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$680.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,167.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,027.54
|
| Rate for Payer: Vantage Medical Group Senior |
$1,027.54
|
|
|
KIT FOR PREPARATION OF TC-99M-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: Aetna of CA Non-Gatekeeper |
$10.05
|
| Rate for Payer: Cash Price |
$7.02
|
| 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 Foundation Hospitals 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-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 |
$328.00 |
| Rate for Payer: Adventist Health Commercial |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$328.00
|
| 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 |
$7.02
|
| Rate for Payer: Cash Price |
$7.02
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$7.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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-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: Aetna of CA Non-Gatekeeper |
$7.72
|
| Rate for Payer: Cash Price |
$5.39
|
| 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 Foundation Hospitals 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 |
$119.41 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$119.41
|
| 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 |
$5.39
|
| Rate for Payer: Cash Price |
$5.39
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$5.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$498.77
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$90.28 |
| Max. Negotiated Rate |
$999.99 |
| Rate for Payer: Adventist Health Commercial |
$99.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$423.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$274.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$374.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$999.99
|
| 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 |
$224.45
|
| Rate for Payer: Cash Price |
$224.45
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$237.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 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: Aetna of CA Non-Gatekeeper |
$321.21
|
| Rate for Payer: Cash Price |
$224.45
|
| 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 Foundation Hospitals 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 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: Aetna of CA Non-Gatekeeper |
$116.65
|
| Rate for Payer: Cash Price |
$81.51
|
| 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 Foundation Hospitals 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 |
$255.88 |
| 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: Anthem Blue Cross of CA HMO/PPO |
$255.88
|
| 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 |
$81.51
|
| Rate for Payer: Cash Price |
$81.51
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$86.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]
|
Facility
|
OP
|
$3,931.20
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$49.63 |
| Max. Negotiated Rate |
$2,948.40 |
| Rate for Payer: Adventist Health Commercial |
$786.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$152.63
|
| Rate for Payer: Blue Shield of California Commercial |
$2,398.03
|
| Rate for Payer: Blue Shield of California EPN |
$1,918.43
|
| Rate for Payer: Cash Price |
$1,769.04
|
| Rate for Payer: Cash Price |
$1,769.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,555.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.59
|
| Rate for Payer: Dignity Health Medicare Advantage |
$54.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,515.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,433.41
|
| Rate for Payer: Heritage Provider Network Senior |
$2,433.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,875.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$711.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$57.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$982.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$66.50
|
| Rate for Payer: Multiplan Commercial |
$2,948.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.59
|
| Rate for Payer: TriValley Medical Group Senior |
$49.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,420.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,301.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$62.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.59
|
| Rate for Payer: Vantage Medical Group Senior |
$54.59
|
|
|
KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]
|
Facility
|
IP
|
$3,931.20
|
|
|
Service Code
|
HCPCS A9587
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$711.55 |
| Max. Negotiated Rate |
$2,948.40 |
| Rate for Payer: Adventist Health Commercial |
$786.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,531.69
|
| Rate for Payer: Cash Price |
$1,769.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,122.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,661.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2,661.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$711.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$982.80
|
| Rate for Payer: Multiplan Commercial |
$2,948.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,420.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,301.62
|
|
|
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: Aetna of CA Non-Gatekeeper |
$57.96
|
| Rate for Payer: Cash Price |
$40.50
|
| 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 Foundation Hospitals 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 |
$133.64 |
| 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: Anthem Blue Cross of CA HMO/PPO |
$133.64
|
| 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 |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$42.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$127.60
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$95.70 |
| Rate for Payer: Adventist Health Commercial |
$25.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.17
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$86.39
|
| Rate for Payer: Heritage Provider Network Senior |
$86.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.90
|
| Rate for Payer: Multiplan Commercial |
$95.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.25
|
|
|
KIT FOR THE PREPARATION OF TC-99M-TETROFOSMIN 0.23 MG IV SOLUTION [98467]
|
Facility
|
OP
|
$127.60
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$254.54 |
| Rate for Payer: Adventist Health Commercial |
$25.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$108.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$70.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.54
|
| Rate for Payer: Blue Shield of California Commercial |
$77.84
|
| Rate for Payer: Blue Shield of California EPN |
$62.27
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$82.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$108.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$108.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$108.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.98
|
| Rate for Payer: Heritage Provider Network Senior |
$78.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$60.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$89.32
|
| Rate for Payer: Multiplan Commercial |
$95.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$108.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$108.46
|
| Rate for Payer: Vantage Medical Group Senior |
$108.46
|
|
|
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: Aetna of CA Non-Gatekeeper |
$486.75
|
| Rate for Payer: Cash Price |
$340.12
|
| 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 Foundation Hospitals 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: Anthem Blue Cross of CA HMO/PPO |
$548.87
|
| 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 |
$340.12
|
| Rate for Payer: Cash Price |
$340.12
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$360.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$258.78 |
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.78
|
| 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 |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$17.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
