|
Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58700
|
| Min. Negotiated Rate |
$948.54 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$948.54
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
IP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$9.02 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.26
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.14
|
| Rate for Payer: Heritage Provider Network Senior |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.02
|
|
|
SAQUINAVIR 500 MG TABLET [40401]
|
Facility
OP
|
$12.02
|
|
|
Service Code
|
NDC 0004-0244-51
|
| Hospital Charge Code |
1710991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.61
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.02
|
| Rate for Payer: Blue Shield of California Commercial |
$7.46
|
| Rate for Payer: Blue Shield of California EPN |
$7.06
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.22
|
| Rate for Payer: Dignity Health Senior |
$10.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.44
|
| Rate for Payer: Heritage Provider Network Senior |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.22
|
| Rate for Payer: Vantage Medical Group Senior |
$10.22
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.32 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Adventist Health Commercial |
$431.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,152.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,481.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,617.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1,339.16
|
| Rate for Payer: Blue Shield of California EPN |
$1,265.84
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: Dignity Health Senior |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,380.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$998.44
|
| Rate for Payer: Heritage Provider Network Senior |
$998.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,039.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$390.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$786.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$720.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG221911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.32 |
| Max. Negotiated Rate |
$1,617.34 |
| Rate for Payer: Adventist Health Commercial |
$431.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,481.49
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,164.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,459.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,459.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$390.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$786.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$720.47
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
OP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.32 |
| Max. Negotiated Rate |
$1,832.99 |
| Rate for Payer: Adventist Health Commercial |
$431.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,152.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,481.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,832.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,186.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,617.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1,339.16
|
| Rate for Payer: Blue Shield of California EPN |
$1,265.84
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,832.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,832.99
|
| Rate for Payer: Dignity Health Senior |
$1,832.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,380.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$998.44
|
| Rate for Payer: Heritage Provider Network Senior |
$998.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,039.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$390.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$786.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$720.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,832.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1,832.99
|
|
|
SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]
|
Facility
IP
|
$2,156.46
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG216968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$390.32 |
| Max. Negotiated Rate |
$1,617.34 |
| Rate for Payer: Adventist Health Commercial |
$431.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,481.49
|
| Rate for Payer: Cash Price |
$970.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$991.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,164.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,459.92
|
| Rate for Payer: Heritage Provider Network Senior |
$1,459.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$390.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$539.12
|
| Rate for Payer: Multiplan Commercial |
$1,617.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$786.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$720.47
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$5,809.20
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$5,809.20 |
| Max. Negotiated Rate |
$5,809.20 |
| Rate for Payer: IEHP Medi-Cal |
$5,809.20
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$9,724.11
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$9,724.11 |
| Max. Negotiated Rate |
$9,724.11 |
| Rate for Payer: IEHP Medi-Cal |
$9,724.11
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$21,990.18
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$21,990.18 |
| Max. Negotiated Rate |
$21,990.18 |
| Rate for Payer: IEHP Medi-Cal |
$21,990.18
|
|
|
SCHIZOPHRENIA
|
Facility
IP
|
$4,661.09
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$4,661.09 |
| Max. Negotiated Rate |
$4,661.09 |
| Rate for Payer: IEHP Medi-Cal |
$4,661.09
|
|
|
Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 49185
|
| Min. Negotiated Rate |
$1,436.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,025.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,228.26
|
| Rate for Payer: Dignity Health Senior |
$2,025.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,025.69
|
| Rate for Payer: Humana Medicare |
$2,025.69
|
| Rate for Payer: IEHP Medi-Cal |
$1,436.29
|
| Rate for Payer: IEHP Medicare Advantage |
$2,025.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,848.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,390.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,552.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,552.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,228.26
|
| Rate for Payer: TriValley Medical Group Senior |
$2,025.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,038.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,228.26
|
| Rate for Payer: Vantage Medical Group Senior |
$2,025.69
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.23
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.04
|
| Rate for Payer: Heritage Provider Network Senior |
$13.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.82
|
| Rate for Payer: Multiplan Commercial |
$14.44
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.54 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-16
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.54
|
| Rate for Payer: Blue Shield of California Commercial |
$13.70
|
| Rate for Payer: Blue Shield of California EPN |
$12.95
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Senior |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$16.54 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.93
|
| Rate for Payer: Heritage Provider Network Senior |
$14.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.54 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.32
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.13
|
| Rate for Payer: Heritage Provider Network Senior |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$19.26
|
|
|
Service Code
|
NDC 45802-580-84
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$16.37 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.44
|
| Rate for Payer: Blue Shield of California Commercial |
$11.96
|
| Rate for Payer: Blue Shield of California EPN |
$11.31
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.37
|
| Rate for Payer: Dignity Health Senior |
$16.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.92
|
| Rate for Payer: Heritage Provider Network Senior |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.82
|
| Rate for Payer: Multiplan Commercial |
$14.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16.37
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$19.39
|
|
|
Service Code
|
NDC 0378-6470-99
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$16.48 |
| Rate for Payer: Adventist Health Commercial |
$3.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$10.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.54
|
| Rate for Payer: Blue Shield of California Commercial |
$12.04
|
| Rate for Payer: Blue Shield of California EPN |
$11.38
|
| Rate for Payer: Cash Price |
$8.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.48
|
| Rate for Payer: Dignity Health Senior |
$16.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.00
|
| Rate for Payer: Heritage Provider Network Senior |
$12.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.85
|
| Rate for Payer: Multiplan Commercial |
$14.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.48
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$22.06
|
|
|
Service Code
|
NDC 0378-6470-97
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$4.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.54
|
| Rate for Payer: Blue Shield of California Commercial |
$13.70
|
| Rate for Payer: Blue Shield of California EPN |
$12.95
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.75
|
| Rate for Payer: Dignity Health Senior |
$18.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.66
|
| Rate for Payer: Heritage Provider Network Senior |
$13.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$16.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.75
|
| Rate for Payer: Vantage Medical Group Senior |
$18.75
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
OP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Adventist Health Commercial |
$4.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.65
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.25
|
| Rate for Payer: Blue Shield of California Commercial |
$14.28
|
| Rate for Payer: Blue Shield of California EPN |
$13.50
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.55
|
| Rate for Payer: Dignity Health Senior |
$19.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.24
|
| Rate for Payer: Heritage Provider Network Senior |
$14.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$17.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.55
|
| Rate for Payer: Vantage Medical Group Senior |
$19.55
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]
|
Facility
IP
|
$23.00
|
|
|
Service Code
|
NDC 45802-580-01
|
| Hospital Charge Code |
1743445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Adventist Health Commercial |
$4.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.80
|
| Rate for Payer: Cash Price |
$10.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.57
|
| Rate for Payer: Heritage Provider Network Senior |
$15.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.75
|
| Rate for Payer: Multiplan Commercial |
$17.25
|
|
|
Scrotoplasty; complicated
|
Facility
OP
|
$12,283.52
|
|
|
Service Code
|
CPT 55180
|
| Min. Negotiated Rate |
$838.08 |
| Max. Negotiated Rate |
$12,283.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| 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 |
$4,547.00
|
| 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 |
$838.08
|
| 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
|
|
|
Scrotoplasty; simple
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 55175
|
| Min. Negotiated Rate |
$81.31 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,355.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,791.29
|
| Rate for Payer: Dignity Health Senior |
$4,355.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,355.72
|
| Rate for Payer: Humana Medicare |
$4,355.72
|
| Rate for Payer: IEHP Medi-Cal |
$81.31
|
| Rate for Payer: IEHP Medicare Advantage |
$4,355.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8,275.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5,139.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,488.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,488.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,791.29
|
| Rate for Payer: TriValley Medical Group Senior |
$4,355.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,533.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,791.29
|
| Rate for Payer: Vantage Medical Group Senior |
$4,355.72
|
|
|
Secondary closure of surgical wound or dehiscence, extensive or complicated
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 13160
|
| Min. Negotiated Rate |
$855.50 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,506.34
|
| Rate for Payer: Dignity Health Senior |
$2,278.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,278.49
|
| Rate for Payer: Humana Medicare |
$2,278.49
|
| Rate for Payer: IEHP Medi-Cal |
$855.50
|
| Rate for Payer: IEHP Medicare Advantage |
$2,278.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,329.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,688.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,870.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,870.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,506.34
|
| Rate for Payer: TriValley Medical Group Senior |
$2,278.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Vantage Medical Group Senior |
$2,278.49
|
|
