|
Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)
|
Facility
OP
|
$13,045.53
|
|
|
Service Code
|
CPT 36832
|
| Min. Negotiated Rate |
$191.66 |
| Max. Negotiated Rate |
$13,045.53 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| 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 |
$7,436.00
|
| 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 |
$191.66
|
| 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
|
|
|
Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)
|
Facility
OP
|
$13,045.53
|
|
|
Service Code
|
CPT 36833
|
| Min. Negotiated Rate |
$850.86 |
| Max. Negotiated Rate |
$13,045.53 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| 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 |
$7,436.00
|
| 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 |
$850.86
|
| 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
|
|
|
Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array
|
Facility
OP
|
$8,077.34
|
|
|
Service Code
|
CPT 63688
|
| Min. Negotiated Rate |
$472.18 |
| Max. Negotiated Rate |
$8,077.34 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,376.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,676.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,251.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,376.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,676.35
|
| Rate for Payer: Dignity Health Senior |
$4,251.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,251.23
|
| Rate for Payer: Humana Medicare |
$4,251.23
|
| Rate for Payer: IEHP Medi-Cal |
$472.18
|
| Rate for Payer: IEHP Medicare Advantage |
$4,251.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,077.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,016.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,356.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,356.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,676.35
|
| Rate for Payer: TriValley Medical Group Senior |
$4,251.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,376.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,676.35
|
| Rate for Payer: Vantage Medical Group Senior |
$4,251.23
|
|
|
Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure
|
Facility
OP
|
$5,547.37
|
|
|
Service Code
|
CPT 66250
|
| Min. Negotiated Rate |
$138.81 |
| Max. Negotiated Rate |
$5,547.37 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,379.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,211.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,919.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| 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: IEHP Medi-Cal |
$138.81
|
| Rate for Payer: 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
|
|
|
Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
|
Facility
OP
|
$32,337.66
|
|
|
Service Code
|
CPT 64569
|
| Min. Negotiated Rate |
$157.70 |
| Max. Negotiated Rate |
$32,337.66 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$25,529.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18,721.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17,019.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25,529.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,721.80
|
| Rate for Payer: Dignity Health Senior |
$17,019.82
|
| Rate for Payer: EPIC Health Plan Medicare |
$17,019.82
|
| Rate for Payer: Humana Medicare |
$17,019.82
|
| Rate for Payer: IEHP Medi-Cal |
$157.70
|
| Rate for Payer: IEHP Medicare Advantage |
$17,019.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32,337.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20,083.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21,444.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21,444.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,721.80
|
| Rate for Payer: TriValley Medical Group Senior |
$17,019.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25,529.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,721.80
|
| Rate for Payer: Vantage Medical Group Senior |
$17,019.82
|
|
|
Rhinectomy; partial
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 30150
|
| Min. Negotiated Rate |
$935.06 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| 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 |
$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 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 |
$935.06
|
| 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
|
|
|
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 30462
|
| Min. Negotiated Rate |
$1,557.68 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 |
$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: IEHP Medi-Cal |
$1,557.68
|
| 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
|
|
|
Rhinoplasty, primary; including major septal repair
|
Facility
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 30420
|
| Min. Negotiated Rate |
$1,315.49 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| 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 |
$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: IEHP Medi-Cal |
$1,315.49
|
| 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
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
IP
|
$96.23
|
|
|
Service Code
|
CPT J2791
|
| Hospital Charge Code |
1712616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$72.17 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.11
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$43.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$51.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$59.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$65.15
|
| Rate for Payer: Heritage Provider Network Senior |
$65.15
|
| Rate for Payer: Heritage Provider Network Senior |
$59.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Multiplan Commercial |
$65.61
|
| Rate for Payer: Multiplan Commercial |
$72.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.15
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE [38072]
|
Facility
OP
|
$96.23
|
|
|
Service Code
|
CPT J2791
|
| Hospital Charge Code |
1712616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$81.80 |
| Rate for Payer: Adventist Health Commercial |
$19.25
|
| Rate for Payer: Adventist Health Commercial |
$17.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$60.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$74.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$48.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$65.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$72.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.61
|
| Rate for Payer: Blue Shield of California Commercial |
$9.91
|
| Rate for Payer: Blue Shield of California Commercial |
$9.91
|
| Rate for Payer: Blue Shield of California EPN |
$9.91
|
| Rate for Payer: Blue Shield of California EPN |
$9.91
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$39.37
|
| Rate for Payer: Cash Price |
$43.30
|
| Rate for Payer: Cash Price |
$43.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$74.36
|
| Rate for Payer: Dignity Health Senior |
$81.80
|
| Rate for Payer: Dignity Health Senior |
$74.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.55
|
| Rate for Payer: Heritage Provider Network Senior |
$40.50
|
| Rate for Payer: Heritage Provider Network Senior |
$44.55
|
| Rate for Payer: IEHP Medi-Cal |
$14.49
|
| Rate for Payer: IEHP Medi-Cal |
$14.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$46.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.06
|
| Rate for Payer: Multiplan Commercial |
$65.61
|
| Rate for Payer: Multiplan Commercial |
$72.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$35.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$32.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$74.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.80
|
| Rate for Payer: Vantage Medical Group Senior |
$74.36
|
| Rate for Payer: Vantage Medical Group Senior |
$81.80
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 15,000 UNIT (3,000 MCG)/13 ML INJ. SOLN [70576]
|
Facility
IP
|
$501.41
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.76 |
| Max. Negotiated Rate |
$376.06 |
| Rate for Payer: Adventist Health Commercial |
$100.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$344.47
|
| Rate for Payer: Cash Price |
$225.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$230.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$270.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$339.45
|
| Rate for Payer: Heritage Provider Network Senior |
$339.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.35
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$182.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$167.52
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 15,000 UNIT (3,000 MCG)/13 ML INJ. SOLN [70576]
|
Facility
OP
|
$501.41
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70576
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.96 |
| Max. Negotiated Rate |
$376.06 |
| Rate for Payer: Adventist Health Commercial |
$100.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$344.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.96
|
| Rate for Payer: Blue Shield of California Commercial |
$36.71
|
| Rate for Payer: Blue Shield of California EPN |
$36.71
|
| Rate for Payer: Cash Price |
$225.63
|
| Rate for Payer: Cash Price |
$225.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$230.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.26
|
| Rate for Payer: Dignity Health Senior |
$36.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$320.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$232.15
|
| Rate for Payer: Heritage Provider Network Senior |
$232.15
|
| Rate for Payer: Humana Medicare |
$32.96
|
| Rate for Payer: IEHP Medi-Cal |
$58.38
|
| Rate for Payer: IEHP Medicare Advantage |
$32.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.53
|
| Rate for Payer: Multiplan Commercial |
$376.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.26
|
| Rate for Payer: TriValley Medical Group Senior |
$32.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$182.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$167.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: Vantage Medical Group Senior |
$32.96
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 1,500 UNIT (300 MCG)/1.3 ML INJECT.SOLN [70575]
|
Facility
OP
|
$498.31
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.96 |
| Max. Negotiated Rate |
$373.73 |
| Rate for Payer: Adventist Health Commercial |
$99.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.96
|
| Rate for Payer: Blue Shield of California Commercial |
$36.71
|
| Rate for Payer: Blue Shield of California EPN |
$36.71
|
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$229.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.26
|
| Rate for Payer: Dignity Health Senior |
$36.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$318.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$230.72
|
| Rate for Payer: Heritage Provider Network Senior |
$230.72
|
| Rate for Payer: Humana Medicare |
$32.96
|
| Rate for Payer: IEHP Medi-Cal |
$58.38
|
| Rate for Payer: IEHP Medicare Advantage |
$32.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.53
|
| Rate for Payer: Multiplan Commercial |
$373.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.26
|
| Rate for Payer: TriValley Medical Group Senior |
$32.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$166.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: Vantage Medical Group Senior |
$32.96
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 1,500 UNIT (300 MCG)/1.3 ML INJECT.SOLN [70575]
|
Facility
IP
|
$498.31
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721148
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.19 |
| Max. Negotiated Rate |
$373.73 |
| Rate for Payer: Adventist Health Commercial |
$99.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.34
|
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$229.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.36
|
| Rate for Payer: Heritage Provider Network Senior |
$337.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.58
|
| Rate for Payer: Multiplan Commercial |
$373.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$181.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$166.49
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 2,500 UNIT (500 MCG)/2.2 ML INJECT.SOLN [70573]
|
Facility
OP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.96 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Adventist Health Commercial |
$98.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.96
|
| Rate for Payer: Blue Shield of California Commercial |
$36.71
|
| Rate for Payer: Blue Shield of California EPN |
$36.71
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.26
|
| Rate for Payer: Dignity Health Senior |
$36.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$316.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.63
|
| Rate for Payer: Heritage Provider Network Senior |
$228.63
|
| Rate for Payer: Humana Medicare |
$32.96
|
| Rate for Payer: IEHP Medi-Cal |
$58.38
|
| Rate for Payer: IEHP Medicare Advantage |
$32.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.53
|
| Rate for Payer: Multiplan Commercial |
$370.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.26
|
| Rate for Payer: TriValley Medical Group Senior |
$32.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: Vantage Medical Group Senior |
$32.96
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 2,500 UNIT (500 MCG)/2.2 ML INJECT.SOLN [70573]
|
Facility
IP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
NDG70573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.38 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Adventist Health Commercial |
$98.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.25
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$334.31
|
| Rate for Payer: Heritage Provider Network Senior |
$334.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.45
|
| Rate for Payer: Multiplan Commercial |
$370.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.98
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]
|
Facility
IP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.38 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Adventist Health Commercial |
$98.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.25
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$266.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$334.31
|
| Rate for Payer: Heritage Provider Network Senior |
$334.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.45
|
| Rate for Payer: Multiplan Commercial |
$370.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.98
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN [70574]
|
Facility
OP
|
$493.81
|
|
|
Service Code
|
CPT J2792
|
| Hospital Charge Code |
1721149
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.96 |
| Max. Negotiated Rate |
$370.36 |
| Rate for Payer: Adventist Health Commercial |
$98.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$339.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$41.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$36.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.96
|
| Rate for Payer: Blue Shield of California Commercial |
$36.71
|
| Rate for Payer: Blue Shield of California EPN |
$36.71
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cash Price |
$222.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$49.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$36.26
|
| Rate for Payer: Dignity Health Senior |
$36.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$316.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.63
|
| Rate for Payer: Heritage Provider Network Senior |
$228.63
|
| Rate for Payer: Humana Medicare |
$32.96
|
| Rate for Payer: IEHP Medi-Cal |
$58.38
|
| Rate for Payer: IEHP Medicare Advantage |
$32.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$62.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$89.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$123.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$41.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$41.53
|
| Rate for Payer: Multiplan Commercial |
$370.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$36.26
|
| Rate for Payer: TriValley Medical Group Senior |
$32.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$180.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$49.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$36.26
|
| Rate for Payer: Vantage Medical Group Senior |
$32.96
|
|
|
Rhytidectomy; cheek, chin, and neck
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15828
|
| Min. Negotiated Rate |
$3,728.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,930.75
|
| Rate for Payer: Dignity Health Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,482.50
|
| Rate for Payer: Humana Medicare |
$4,482.50
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,516.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,289.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,647.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,647.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,930.75
|
| Rate for Payer: TriValley Medical Group Senior |
$4,482.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
IP
|
$0.74
|
|
|
Service Code
|
NDC 65862-207-68
|
| Hospital Charge Code |
ERX11287
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
|
|
RIBAVIRIN 200 MG TABLET [11287]
|
Facility
OP
|
$0.74
|
|
|
Service Code
|
NDC 65862-207-68
|
| Hospital Charge Code |
ERX11287
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: Dignity Health Senior |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 4329256000
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 7985420195
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET [11288]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 761003220
|
| Hospital Charge Code |
1712617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
