|
RENAL DIALYSIS ACCESS DEVICE PROCEDURES
|
Facility
IP
|
$12,100.92
|
|
|
Service Code
|
APR-DRG 4442
|
| Min. Negotiated Rate |
$12,100.92 |
| Max. Negotiated Rate |
$12,100.92 |
| Rate for Payer: IEHP Medi-Cal |
$12,100.92
|
|
|
RENAL DIALYSIS ACCESS DEVICE PROCEDURES
|
Facility
IP
|
$17,853.40
|
|
|
Service Code
|
APR-DRG 4443
|
| Min. Negotiated Rate |
$17,853.40 |
| Max. Negotiated Rate |
$17,853.40 |
| Rate for Payer: IEHP Medi-Cal |
$17,853.40
|
|
|
Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 50561
|
| Min. Negotiated Rate |
$658.62 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$658.62
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 50553
|
| Min. Negotiated Rate |
$617.37 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,465.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,111.51
|
| Rate for Payer: Dignity Health Senior |
$6,465.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,465.01
|
| Rate for Payer: Humana Medicare |
$6,465.01
|
| Rate for Payer: IEHP Medi-Cal |
$617.37
|
| Rate for Payer: IEHP Medicare Advantage |
$6,465.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12,283.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,628.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,145.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,145.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,111.51
|
| Rate for Payer: TriValley Medical Group Senior |
$6,465.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,697.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,111.51
|
| Rate for Payer: Vantage Medical Group Senior |
$6,465.01
|
|
|
Repair blood vessel, direct; intrathoracic, without bypass
|
Facility
OP
|
$10,742.00
|
|
|
Service Code
|
CPT 35216
|
| Min. Negotiated Rate |
$1,708.68 |
| Max. Negotiated Rate |
$10,742.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,275.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,742.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$1,708.68
|
|
|
Repair blood vessel, direct; neck
|
Facility
OP
|
$13,045.53
|
|
|
Service Code
|
CPT 35201
|
| Min. Negotiated Rate |
$1,626.21 |
| Max. Negotiated Rate |
$13,045.53 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6,866.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,552.68
|
| Rate for Payer: Dignity Health Senior |
$6,866.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,866.07
|
| Rate for Payer: Humana Medicare |
$6,866.07
|
| Rate for Payer: IEHP Medi-Cal |
$1,626.21
|
| Rate for Payer: IEHP Medicare Advantage |
$6,866.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,045.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,101.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,651.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,651.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,552.68
|
| Rate for Payer: TriValley Medical Group Senior |
$6,866.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,299.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,552.68
|
| Rate for Payer: Vantage Medical Group Senior |
$6,866.07
|
|
|
Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13152
|
| Min. Negotiated Rate |
$526.19 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$526.19
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13153
|
| Min. Negotiated Rate |
$29.62 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$29.62
|
|
|
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13131
|
| Min. Negotiated Rate |
$201.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: IEHP Medi-Cal |
$201.54
|
| Rate for Payer: IEHP Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13132
|
| Min. Negotiated Rate |
$394.93 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$394.93
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13133
|
| Min. Negotiated Rate |
$135.33 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$135.33
|
|
|
Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13120
|
| Min. Negotiated Rate |
$516.13 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$516.13
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13121
|
| Min. Negotiated Rate |
$263.09 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$263.09
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13122
|
| Min. Negotiated Rate |
$181.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$181.71
|
|
|
Repair, complex, trunk; 1.1 cm to 2.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13100
|
| Min. Negotiated Rate |
$172.49 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$172.49
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, trunk; 2.6 cm to 7.5 cm
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13101
|
| Min. Negotiated Rate |
$577.56 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$577.56
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13102
|
| Min. Negotiated Rate |
$78.41 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$78.41
|
|
|
Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26420
|
| Min. Negotiated Rate |
$4,044.21 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: AlphaCare 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: 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
|
|
|
Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26418
|
| Min. Negotiated Rate |
$457.08 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: IEHP Medi-Cal |
$457.08
|
| Rate for Payer: IEHP Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26410
|
| Min. Negotiated Rate |
$465.78 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: IEHP Medi-Cal |
$465.78
|
| Rate for Payer: IEHP Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Repair fistula; oromaxillary (combine with 31030 if antrotomy is included)
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 30580
|
| Min. Negotiated Rate |
$580.79 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| 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: IEHP Medi-Cal |
$580.79
|
| Rate for Payer: 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
|
|
|
Repair fistula; oronasal
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 30600
|
| Min. Negotiated Rate |
$102.80 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| 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: IEHP Medi-Cal |
$102.80
|
| Rate for Payer: 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
|
|
|
Repair incomplete circumcision
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54163
|
| Min. Negotiated Rate |
$275.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: IEHP Medi-Cal |
$275.29
|
| Rate for Payer: IEHP Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,544.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
Repair initial femoral hernia, any age; incarcerated or strangulated
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 49553
|
| Min. Negotiated Rate |
$123.71 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,483.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,322.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,483.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,754.88
|
| Rate for Payer: Dignity Health Senior |
$4,322.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,322.62
|
| Rate for Payer: Humana Medicare |
$4,322.62
|
| Rate for Payer: IEHP Medi-Cal |
$123.71
|
| Rate for Payer: IEHP Medicare Advantage |
$4,322.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,212.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,100.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,446.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,446.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,754.88
|
| Rate for Payer: TriValley Medical Group Senior |
$4,322.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,483.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: Vantage Medical Group Senior |
$4,322.62
|
|
|
Repair initial inguinal hernia, age 5 years or older; reducible
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 49505
|
| Min. Negotiated Rate |
$536.66 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,483.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,322.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,483.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,754.88
|
| Rate for Payer: Dignity Health Senior |
$4,322.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,322.62
|
| Rate for Payer: Humana Medicare |
$4,322.62
|
| Rate for Payer: IEHP Medi-Cal |
$536.66
|
| Rate for Payer: IEHP Medicare Advantage |
$4,322.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,212.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,100.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,446.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,446.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,754.88
|
| Rate for Payer: TriValley Medical Group Senior |
$4,322.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,483.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,754.88
|
| Rate for Payer: Vantage Medical Group Senior |
$4,322.62
|
|
