|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
OP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.41 |
| Max. Negotiated Rate |
$4,230.00 |
| Rate for Payer: Adventist Health Commercial |
$1,128.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$494.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,874.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$219.41
|
| Rate for Payer: Blue Shield of California Commercial |
$636.21
|
| Rate for Payer: Blue Shield of California EPN |
$636.21
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,594.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: Dignity Health Senior |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,609.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$251.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,611.32
|
| Rate for Payer: Heritage Provider Network Senior |
$2,611.32
|
| Rate for Payer: Humana Medicare |
$251.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$398.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$477.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,020.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,410.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$316.52
|
| Rate for Payer: Multiplan Commercial |
$4,230.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,256.00
|
| Rate for Payer: TriValley Medical Group Senior |
$2,256.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
|
THIOTEPA 100 MG SOLUTION FOR INJECTION [216126]
|
Facility
|
IP
|
$5,640.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
ERX216126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,020.84 |
| Max. Negotiated Rate |
$4,230.00 |
| Rate for Payer: Adventist Health Commercial |
$1,128.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3,874.68
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,594.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,045.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,818.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3,818.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,020.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,410.00
|
| Rate for Payer: Multiplan Commercial |
$4,230.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,056.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,884.32
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
1755061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$486.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$609.30
|
| Rate for Payer: Heritage Provider Network Senior |
$609.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION [7901]
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
CPT J9340
|
| Hospital Charge Code |
1755061
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Adventist Health Commercial |
$180.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$494.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$618.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$314.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$276.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$219.41
|
| Rate for Payer: Blue Shield of California Commercial |
$636.21
|
| Rate for Payer: Blue Shield of California EPN |
$636.21
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$414.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$276.33
|
| Rate for Payer: Dignity Health Senior |
$276.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$576.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$251.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$416.70
|
| Rate for Payer: Heritage Provider Network Senior |
$416.70
|
| Rate for Payer: Humana Medicare |
$251.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$398.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$251.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$477.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$162.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$296.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$225.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$316.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$316.52
|
| Rate for Payer: Multiplan Commercial |
$675.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$360.00
|
| Rate for Payer: TriValley Medical Group Senior |
$360.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$328.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$300.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$276.33
|
| Rate for Payer: Vantage Medical Group Senior |
$251.20
|
|
|
THIOTHIXENE 2 MG CAPSULE [7904]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 51079-587-01
|
| Hospital Charge Code |
1711269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.79
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.40
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.03
|
| Rate for Payer: Dignity Health Senior |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.48
|
| Rate for Payer: Heritage Provider Network Senior |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.03
|
| Rate for Payer: Vantage Medical Group Senior |
$2.03
|
|
|
THIOTHIXENE 2 MG CAPSULE [7904]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 51079-587-01
|
| Hospital Charge Code |
1711269
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.64
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.79
|
|
|
Thoracoscopy, surgical; with thoracic sympathectomy
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 32664
|
| Min. Negotiated Rate |
$159.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| 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 |
$159.71
|
|
|
Thoracotomy; with cardiac massage
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 32160
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,569.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,054.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.24
|
|
|
Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear
|
Facility
|
OP
|
$9,792.00
|
|
|
Service Code
|
CPT 32110
|
| Min. Negotiated Rate |
$1,052.39 |
| Max. Negotiated Rate |
$9,792.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,941.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,052.39
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
OP
|
$80.93
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
NDG221104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$68.79 |
| Rate for Payer: Adventist Health Commercial |
$16.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$68.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.70
|
| Rate for Payer: Blue Shield of California Commercial |
$50.26
|
| Rate for Payer: Blue Shield of California EPN |
$47.51
|
| Rate for Payer: Cash Price |
$36.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$52.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$68.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.79
|
| Rate for Payer: Dignity Health Senior |
$68.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.10
|
| Rate for Payer: Heritage Provider Network Senior |
$50.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.23
|
| Rate for Payer: Multiplan Commercial |
$60.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.37
|
| Rate for Payer: TriValley Medical Group Senior |
$32.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.79
|
| Rate for Payer: Vantage Medical Group Senior |
$68.79
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 10 ML TOPICAL SYRINGE [221104]
|
Facility
|
IP
|
$80.93
|
|
|
Service Code
|
NDC 0338-9568-01
|
| Hospital Charge Code |
NDG221104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$60.70 |
| Rate for Payer: Adventist Health Commercial |
$16.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$55.60
|
| Rate for Payer: Cash Price |
$36.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.79
|
| Rate for Payer: Heritage Provider Network Senior |
$54.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.23
|
| Rate for Payer: Multiplan Commercial |
$60.70
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
OP
|
$82.46
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
NDG221103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.93 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Adventist Health Commercial |
$16.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$70.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.84
|
| Rate for Payer: Blue Shield of California Commercial |
$51.21
|
| Rate for Payer: Blue Shield of California EPN |
$48.40
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.09
|
| Rate for Payer: Dignity Health Senior |
$70.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$51.04
|
| Rate for Payer: Heritage Provider Network Senior |
$51.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$61.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.98
|
| Rate for Payer: TriValley Medical Group Senior |
$32.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.09
|
| Rate for Payer: Vantage Medical Group Senior |
$70.09
|
|
|
THROMBIN(HUMAN)-FIBRINOGEN-APROTININ SYN-CALCIUM 4 ML TOPICAL SYRINGE [221103]
|
Facility
|
IP
|
$82.46
|
|
|
Service Code
|
NDC 0338-9564-01
|
| Hospital Charge Code |
NDG221103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.93 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Adventist Health Commercial |
$16.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.65
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.83
|
| Rate for Payer: Heritage Provider Network Senior |
$55.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.62
|
| Rate for Payer: Multiplan Commercial |
$61.84
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$77.40 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.90
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.87
|
| Rate for Payer: Heritage Provider Network Senior |
$69.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$55.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Blue Shield of California Commercial |
$64.09
|
| Rate for Payer: Blue Shield of California EPN |
$60.58
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Senior |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.88
|
| Rate for Payer: Heritage Provider Network Senior |
$63.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$49.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.28
|
| Rate for Payer: TriValley Medical Group Senior |
$41.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
IP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0322-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$77.40 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.90
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.87
|
| Rate for Payer: Heritage Provider Network Senior |
$69.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [89570]
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
NDC 0338-0324-01
|
| Hospital Charge Code |
ERX89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$87.72 |
| Rate for Payer: Adventist Health Commercial |
$20.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$55.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$87.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$77.40
|
| Rate for Payer: Blue Shield of California Commercial |
$64.09
|
| Rate for Payer: Blue Shield of California EPN |
$60.58
|
| Rate for Payer: Cash Price |
$46.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$87.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$87.72
|
| Rate for Payer: Dignity Health Senior |
$87.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$63.88
|
| Rate for Payer: Heritage Provider Network Senior |
$63.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$49.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.80
|
| Rate for Payer: Multiplan Commercial |
$77.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$41.28
|
| Rate for Payer: TriValley Medical Group Senior |
$41.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$87.72
|
| Rate for Payer: Vantage Medical Group Senior |
$87.72
|
|
|
THYROID DISORDERS
|
Facility
|
IP
|
$3,982.56
|
|
|
Service Code
|
APR-DRG 4271
|
| Min. Negotiated Rate |
$3,982.56 |
| Max. Negotiated Rate |
$3,982.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,982.56
|
|
|
THYROID DISORDERS
|
Facility
|
IP
|
$15,280.61
|
|
|
Service Code
|
APR-DRG 4274
|
| Min. Negotiated Rate |
$15,280.61 |
| Max. Negotiated Rate |
$15,280.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,280.61
|
|
|
THYROID DISORDERS
|
Facility
|
IP
|
$8,749.11
|
|
|
Service Code
|
APR-DRG 4273
|
| Min. Negotiated Rate |
$8,749.11 |
| Max. Negotiated Rate |
$8,749.11 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,749.11
|
|
|
THYROID DISORDERS
|
Facility
|
IP
|
$5,492.83
|
|
|
Service Code
|
APR-DRG 4272
|
| Min. Negotiated Rate |
$5,492.83 |
| Max. Negotiated Rate |
$5,492.83 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,492.83
|
|
|
Thyroidectomy, including substernal thyroid; cervical approach
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 60271
|
| Min. Negotiated Rate |
$1,233.01 |
| 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 |
$10,742.00
|
| 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 |
$1,233.01
|
| 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
|
|
|
Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach
|
Facility
|
OP
|
$10,742.00
|
|
|
Service Code
|
CPT 60270
|
| Min. Negotiated Rate |
$282.84 |
| Max. Negotiated Rate |
$10,742.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,816.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,742.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$282.84
|
|
|
Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 60260
|
| Min. Negotiated Rate |
$986.76 |
| 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 |
$8,576.00
|
| 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 Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$986.76
|
| 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
|
|
|
Thyroidectomy, total or complete
|
Facility
|
OP
|
$13,697.50
|
|
|
Service Code
|
CPT 60240
|
| Min. Negotiated Rate |
$210.24 |
| Max. Negotiated Rate |
$13,697.50 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,209.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,930.13
|
| Rate for Payer: Dignity Health Senior |
$7,209.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,209.21
|
| Rate for Payer: Humana Medicare |
$7,209.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$210.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,209.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,697.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,506.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,083.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,083.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,930.13
|
| Rate for Payer: TriValley Medical Group Senior |
$7,209.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: Vantage Medical Group Senior |
$7,209.21
|
|
