|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
IP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$566.86 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$519.25
|
| 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 Permanente of CA Medi-Cal |
$136.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$188.96
|
| Rate for Payer: Multiplan Commercial |
$566.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.52
|
|
|
KIT FOR THE PREP OF TC-99M-TILMANOCEPT 250 MCG SOLUTION FOR INJECTION [223025]
|
Facility
OP
|
$755.82
|
|
|
Service Code
|
CPT A9520
|
| Hospital Charge Code |
ERX223025
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$642.45 |
| Rate for Payer: Adventist Health Commercial |
$151.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$642.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$415.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$566.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$483.88
|
| Rate for Payer: Blue Shield of California Commercial |
$469.36
|
| Rate for Payer: Blue Shield of California EPN |
$443.67
|
| 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 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 |
$364.31
|
| 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 |
$566.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$275.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$252.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$642.45
|
| Rate for Payer: Vantage Medical Group Senior |
$642.45
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
IP
|
$11,567.65
|
|
|
Service Code
|
APR-DRG 3131
|
| Min. Negotiated Rate |
$11,567.65 |
| Max. Negotiated Rate |
$11,567.65 |
| Rate for Payer: IEHP Medi-Cal |
$11,567.65
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
IP
|
$15,228.87
|
|
|
Service Code
|
APR-DRG 3132
|
| Min. Negotiated Rate |
$15,228.87 |
| Max. Negotiated Rate |
$15,228.87 |
| Rate for Payer: IEHP Medi-Cal |
$15,228.87
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
IP
|
$34,595.52
|
|
|
Service Code
|
APR-DRG 3134
|
| Min. Negotiated Rate |
$34,595.52 |
| Max. Negotiated Rate |
$34,595.52 |
| Rate for Payer: IEHP Medi-Cal |
$34,595.52
|
|
|
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT
|
Facility
IP
|
$22,218.02
|
|
|
Service Code
|
APR-DRG 3133
|
| Min. Negotiated Rate |
$22,218.02 |
| Max. Negotiated Rate |
$22,218.02 |
| Rate for Payer: IEHP Medi-Cal |
$22,218.02
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWT0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWC4JC
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWC3JC
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWC0JC
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SUW09Z
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SUC09C
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QUD0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWD3JC
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QRF0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QRD4JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWD0JC
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWV4JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QPF4JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QRD0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QPD0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0QPF0JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWW3JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWU3JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
|
Knee Implant - #2072
|
Facility
IP
|
$8,448.00
|
|
|
Service Code
|
ICD 0SWW4JZ
|
| Min. Negotiated Rate |
$8,448.00 |
| Max. Negotiated Rate |
$8,448.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,448.00
|
|
