|
RASAGILINE 1 MG TABLET [76481]
|
Facility
|
IP
|
$17.80
|
|
|
Service Code
|
NDC 47781-690-30
|
| Hospital Charge Code |
1711908
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$13.35 |
| Rate for Payer: Adventist Health Commercial |
$3.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.23
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.05
|
| Rate for Payer: Heritage Provider Network Senior |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Commercial |
$13.35
|
|
|
RASAGILINE 1 MG TABLET [76481]
|
Facility
|
IP
|
$8.25
|
|
|
Service Code
|
NDC 0093-3061-56
|
| Hospital Charge Code |
1711908
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$6.19 |
| Rate for Payer: Adventist Health Commercial |
$1.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.67
|
| Rate for Payer: Cash Price |
$3.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.59
|
| Rate for Payer: Heritage Provider Network Senior |
$5.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.06
|
| Rate for Payer: Multiplan Commercial |
$6.19
|
|
|
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION [33591]
|
Facility
|
OP
|
$1,276.65
|
|
|
Service Code
|
CPT J2783
|
| Hospital Charge Code |
1722030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.21 |
| Max. Negotiated Rate |
$957.49 |
| Rate for Payer: Adventist Health Commercial |
$255.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$902.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$877.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$459.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$403.99
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$403.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$221.21
|
| Rate for Payer: Blue Shield of California Commercial |
$331.05
|
| Rate for Payer: Blue Shield of California EPN |
$331.05
|
| Rate for Payer: Cash Price |
$574.49
|
| Rate for Payer: Cash Price |
$574.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$587.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$550.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$403.99
|
| Rate for Payer: Dignity Health Senior |
$403.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$817.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$367.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$591.09
|
| Rate for Payer: Heritage Provider Network Senior |
$591.09
|
| Rate for Payer: Humana Medicare |
$367.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$367.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$697.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$231.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$433.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$319.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$462.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$462.76
|
| Rate for Payer: Multiplan Commercial |
$957.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$510.66
|
| Rate for Payer: TriValley Medical Group Senior |
$510.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$465.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$426.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$550.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$403.99
|
| Rate for Payer: Vantage Medical Group Senior |
$367.27
|
|
|
RASBURICASE 1.5 MG INTRAVENOUS SOLUTION [33591]
|
Facility
|
IP
|
$1,276.65
|
|
|
Service Code
|
CPT J2783
|
| Hospital Charge Code |
1722030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$231.07 |
| Max. Negotiated Rate |
$957.49 |
| Rate for Payer: Adventist Health Commercial |
$255.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$877.06
|
| Rate for Payer: Cash Price |
$574.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$587.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$689.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$864.29
|
| Rate for Payer: Heritage Provider Network Senior |
$864.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$231.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$319.16
|
| Rate for Payer: Multiplan Commercial |
$957.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$465.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$426.53
|
|
|
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION [229668]
|
Facility
|
OP
|
$2,561.60
|
|
|
Service Code
|
CPT J1303
|
| Hospital Charge Code |
NDG229668A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$217.74 |
| Max. Negotiated Rate |
$1,921.20 |
| Rate for Payer: Adventist Health Commercial |
$512.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$544.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,759.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$277.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$243.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$243.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$456.19
|
| Rate for Payer: Blue Shield of California Commercial |
$217.74
|
| Rate for Payer: Blue Shield of California EPN |
$217.74
|
| Rate for Payer: Cash Price |
$1,152.72
|
| Rate for Payer: Cash Price |
$1,152.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,178.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$277.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.95
|
| Rate for Payer: Dignity Health Senior |
$243.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,639.42
|
| Rate for Payer: EPIC Health Plan Medicare |
$221.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,186.02
|
| Rate for Payer: Heritage Provider Network Senior |
$1,186.02
|
| Rate for Payer: Humana Medicare |
$221.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$352.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$221.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$421.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$463.65
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$261.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$640.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$279.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$279.43
|
| Rate for Payer: Multiplan Commercial |
$1,921.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,024.64
|
| Rate for Payer: TriValley Medical Group Senior |
$1,024.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$933.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$855.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$277.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.95
|
| Rate for Payer: Vantage Medical Group Senior |
$243.95
|
|
|
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION [229668]
|
Facility
|
IP
|
$2,561.60
|
|
|
Service Code
|
CPT J1303
|
| Hospital Charge Code |
NDG229668A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$463.65 |
| Max. Negotiated Rate |
$1,921.20 |
| Rate for Payer: Adventist Health Commercial |
$512.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,759.82
|
| Rate for Payer: Cash Price |
$1,152.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,178.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,383.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,734.20
|
| Rate for Payer: Heritage Provider Network Senior |
$1,734.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$463.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$640.40
|
| Rate for Payer: Multiplan Commercial |
$1,921.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$933.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$855.83
|
|
|
Realignment of extensor tendon, hand, each tendon
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26437
|
| Min. Negotiated Rate |
$173.08 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$173.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26541
|
| Min. Negotiated Rate |
$775.93 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$775.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 25337
|
| Min. Negotiated Rate |
$123.71 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$123.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21146
|
| Min. Negotiated Rate |
$1,586.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,586.13
|
|
|
Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21142
|
| Min. Negotiated Rate |
$336.27 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$336.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21147
|
| Min. Negotiated Rate |
$348.47 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$348.47
|
|
|
Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21143
|
| Min. Negotiated Rate |
$1,748.17 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,748.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21141
|
| Min. Negotiated Rate |
$1,621.56 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,621.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21145
|
| Min. Negotiated Rate |
$289.24 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.24
|
|
|
Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure)
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 69310
|
| Min. Negotiated Rate |
$197.46 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$197.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 stage or first stage
|
Facility
|
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 67973
|
| Min. Negotiated Rate |
$986.76 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$986.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, 1 stage or first stage
|
Facility
|
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 67971
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,211.64
|
| Rate for Payer: Dignity Health Senior |
$2,919.67
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,919.67
|
| Rate for Payer: Humana Medicare |
$2,919.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$157.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,919.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,547.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,445.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,678.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,678.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,211.64
|
| Rate for Payer: TriValley Medical Group Senior |
$2,919.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2,919.67
|
|
|
Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21244
|
| Min. Negotiated Rate |
$245.67 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$245.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21249
|
| Min. Negotiated Rate |
$1,580.90 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,580.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21248
|
| Min. Negotiated Rate |
$199.21 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$199.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21196
|
| Min. Negotiated Rate |
$1,626.21 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,626.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21195
|
| Min. Negotiated Rate |
$289.24 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$289.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 21193
|
| Min. Negotiated Rate |
$278.77 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$278.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26502
|
| Min. Negotiated Rate |
$105.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
