|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 6958485310
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 5348932801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 5348932801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 6068747611
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 6068747601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 1672922601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 6068747601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
SPIRONOLACTONE 50 MG TABLET [11426]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 1672922601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
SPIRONOLACTONE/HCTZ ORAL SUSP COMPOUND 5 MG/ML [4080340]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 9994080340
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
SPIRONOLACTONE/HCTZ ORAL SUSP COMPOUND 5 MG/ML [4080340]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 9994080340
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
SPIRONOLACTONE ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080339]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994080339
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
SPIRONOLACTONE ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080339]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994080339
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$43,841.25
|
|
|
Service Code
|
MSDRG 800
|
| Min. Negotiated Rate |
$32,717.35 |
| Max. Negotiated Rate |
$43,841.25 |
| Rate for Payer: EPIC Health Plan Medicare |
$32,717.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32,717.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37,624.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43,841.25
|
|
|
SPLENIC PROCEDURES WITH MCC
|
Facility
|
IP
|
$70,244.96
|
|
|
Service Code
|
MSDRG 799
|
| Min. Negotiated Rate |
$52,421.61 |
| Max. Negotiated Rate |
$70,244.96 |
| Rate for Payer: EPIC Health Plan Medicare |
$52,421.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$52,421.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$60,284.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$70,244.96
|
|
|
SPLENIC PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$30,013.63
|
|
|
Service Code
|
MSDRG 801
|
| Min. Negotiated Rate |
$22,398.23 |
| Max. Negotiated Rate |
$30,013.63 |
| Rate for Payer: EPIC Health Plan Medicare |
$22,398.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,398.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$25,757.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$30,013.63
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 15120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,557.82 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,557.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$5,013.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,557.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,557.82
|
| Rate for Payer: Heritage Provider Network Senior |
$5,606.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,557.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8,659.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5,241.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6,107.48
|
| Rate for Payer: Multiplan WC |
$7,411.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,013.60
|
| Rate for Payer: TriValley Medical Group Senior |
$5,013.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,836.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5,013.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4,557.82
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC
|
Facility
|
IP
|
$15,355.31
|
|
|
Service Code
|
MSDRG 537
|
| Min. Negotiated Rate |
$11,459.19 |
| Max. Negotiated Rate |
$15,355.31 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,459.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,459.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,178.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,355.31
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC
|
Facility
|
IP
|
$11,762.14
|
|
|
Service Code
|
MSDRG 538
|
| Min. Negotiated Rate |
$8,777.72 |
| Max. Negotiated Rate |
$11,762.14 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,777.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,777.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,094.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,762.14
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS
|
Facility
|
OP
|
$10,001.00
|
|
|
Service Code
|
CPT 37765
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,061.05 |
| Max. Negotiated Rate |
$10,001.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,467.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,061.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,467.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,061.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,061.05
|
| Rate for Payer: Heritage Provider Network Senior |
$4,995.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,061.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,715.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,670.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,441.81
|
| Rate for Payer: Multiplan WC |
$6,372.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,467.15
|
| Rate for Payer: TriValley Medical Group Senior |
$4,467.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,091.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,467.15
|
| Rate for Payer: Vantage Medical Group Senior |
$4,061.05
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
|
OP
|
$234.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$199.41 |
| Rate for Payer: Cigna of CA HMO/PPO |
$107.92
|
| Rate for Payer: Adventist Health Commercial |
$46.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$144.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$199.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$129.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$175.95
|
| Rate for Payer: Blue Shield of California Commercial |
$143.11
|
| Rate for Payer: Blue Shield of California EPN |
$114.48
|
| Rate for Payer: Cash Price |
$105.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$199.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$199.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$199.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$150.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.62
|
| Rate for Payer: Heritage Provider Network Senior |
$108.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$111.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$164.22
|
| Rate for Payer: Multiplan Commercial |
$175.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$93.84
|
| Rate for Payer: TriValley Medical Group Senior |
$93.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$199.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$199.41
|
| Rate for Payer: Vantage Medical Group Senior |
$199.41
|
|
|
STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION [221295]
|
Facility
|
IP
|
$234.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.46 |
| Max. Negotiated Rate |
$175.95 |
| Rate for Payer: Adventist Health Commercial |
$46.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$151.08
|
| Rate for Payer: Cash Price |
$105.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$126.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$108.62
|
| Rate for Payer: Heritage Provider Network Senior |
$108.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.65
|
| Rate for Payer: Multiplan Commercial |
$175.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.68
|
|
|
STERILE TALC 5 GRAM INTRAPLEURAL SUSPENSION [37812]
|
Facility
|
IP
|
$119.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.61 |
| Max. Negotiated Rate |
$89.55 |
| Rate for Payer: Adventist Health Commercial |
$23.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.89
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.28
|
| Rate for Payer: Heritage Provider Network Senior |
$55.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.85
|
| Rate for Payer: Multiplan Commercial |
$89.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.53
|
|
|
STERILE TALC 5 GRAM INTRAPLEURAL SUSPENSION [37812]
|
Facility
|
OP
|
$119.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.61 |
| Max. Negotiated Rate |
$101.49 |
| Rate for Payer: Adventist Health Commercial |
$23.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$101.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.55
|
| Rate for Payer: Blue Shield of California Commercial |
$72.83
|
| Rate for Payer: Blue Shield of California EPN |
$58.27
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$101.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$101.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.28
|
| Rate for Payer: Heritage Provider Network Senior |
$55.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$56.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$83.58
|
| Rate for Payer: Multiplan Commercial |
$89.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$47.76
|
| Rate for Payer: TriValley Medical Group Senior |
$47.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$101.49
|
| Rate for Payer: Vantage Medical Group Senior |
$101.49
|
|
|
STERILE WATER FOR INJECTION. [4081186]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
