|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]
|
Facility
OP
|
$282.00
|
|
|
Service Code
|
NDC 63323-762-17
|
| Hospital Charge Code |
1755756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$150.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$155.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$211.50
|
| Rate for Payer: Blue Shield of California Commercial |
$175.12
|
| Rate for Payer: Blue Shield of California EPN |
$165.53
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.70
|
| Rate for Payer: Dignity Health Senior |
$239.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.57
|
| Rate for Payer: Heritage Provider Network Senior |
$130.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$94.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.70
|
| Rate for Payer: Vantage Medical Group Senior |
$239.70
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
OP
|
$0.57
|
|
|
Service Code
|
NDC 50268-757-15
|
| Hospital Charge Code |
1712177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
OP
|
$0.57
|
|
|
Service Code
|
NDC 50268-757-11
|
| Hospital Charge Code |
1712177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
IP
|
$0.57
|
|
|
Service Code
|
NDC 50268-757-15
|
| Hospital Charge Code |
1712177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
TORSEMIDE 100 MG TABLET [18294]
|
Facility
IP
|
$0.57
|
|
|
Service Code
|
NDC 50268-757-11
|
| Hospital Charge Code |
1712177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 57237-139-01
|
| Hospital Charge Code |
1712175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
OP
|
$0.19
|
|
|
Service Code
|
NDC 57237-139-01
|
| Hospital Charge Code |
1712175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
OP
|
$0.37
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
1712175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TORSEMIDE 10 MG TABLET [18292]
|
Facility
IP
|
$0.37
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
1712175
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 31722-531-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
OP
|
$0.43
|
|
|
Service Code
|
NDC 68084-539-11
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 31722-531-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 65862-127-01
|
| Hospital Charge Code |
1712176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
|
Facility
OP
|
$10,742.00
|
|
|
Service Code
|
CPT 58150
|
| Min. Negotiated Rate |
$1,264.72 |
| Max. Negotiated Rate |
$10,742.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| 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 |
$1,264.72
|
|
|
Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 22858
|
| Min. Negotiated Rate |
$131.91 |
| 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 |
$8,576.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$131.91
|
|
|
Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical
|
Facility
OP
|
$44,240.59
|
|
|
Service Code
|
CPT 22856
|
| Min. Negotiated Rate |
$383.90 |
| Max. Negotiated Rate |
$44,240.59 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,245.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$34,926.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25,612.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23,284.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$34,926.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$25,612.97
|
| Rate for Payer: Dignity Health Senior |
$23,284.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$23,284.52
|
| Rate for Payer: Humana Medicare |
$23,284.52
|
| Rate for Payer: IEHP Medi-Cal |
$383.90
|
| Rate for Payer: IEHP Medicare Advantage |
$23,284.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$44,240.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$27,475.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29,338.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29,338.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$25,612.97
|
| Rate for Payer: TriValley Medical Group Senior |
$23,284.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$34,926.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25,612.97
|
| Rate for Payer: Vantage Medical Group Senior |
$23,284.52
|
|
|
Total thyroid lobectomy, unilateral; with or without isthmusectomy
|
Facility
OP
|
$13,697.50
|
|
|
Service Code
|
CPT 60220
|
| Min. Negotiated Rate |
$173.08 |
| Max. Negotiated Rate |
$13,697.50 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,209.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,930.13
|
| Rate for Payer: Dignity Health Senior |
$7,209.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,209.21
|
| Rate for Payer: Humana Medicare |
$7,209.21
|
| Rate for Payer: IEHP Medi-Cal |
$173.08
|
| Rate for Payer: IEHP Medicare Advantage |
$7,209.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,697.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,506.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,083.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,083.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,930.13
|
| Rate for Payer: TriValley Medical Group Senior |
$7,209.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,813.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,930.13
|
| Rate for Payer: Vantage Medical Group Senior |
$7,209.21
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$11,582.58
|
|
|
Service Code
|
APR-DRG 8164
|
| Min. Negotiated Rate |
$11,582.58 |
| Max. Negotiated Rate |
$11,582.58 |
| Rate for Payer: IEHP Medi-Cal |
$11,582.58
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$6,418.07
|
|
|
Service Code
|
APR-DRG 8163
|
| Min. Negotiated Rate |
$6,418.07 |
| Max. Negotiated Rate |
$6,418.07 |
| Rate for Payer: IEHP Medi-Cal |
$6,418.07
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$4,856.09
|
|
|
Service Code
|
APR-DRG 8162
|
| Min. Negotiated Rate |
$4,856.09 |
| Max. Negotiated Rate |
$4,856.09 |
| Rate for Payer: IEHP Medi-Cal |
$4,856.09
|
|
|
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
|
Facility
IP
|
$4,586.47
|
|
|
Service Code
|
APR-DRG 8161
|
| Min. Negotiated Rate |
$4,586.47 |
| Max. Negotiated Rate |
$4,586.47 |
| Rate for Payer: IEHP Medi-Cal |
$4,586.47
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
IP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$374.25 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.81
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$269.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$337.82
|
| Rate for Payer: Heritage Provider Network Senior |
$337.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
|
|
TPN NICU NO DOSE REVISED [4082636]
|
Facility
OP
|
$499.00
|
|
|
Service Code
|
NDC 9994-0816-36
|
| Hospital Charge Code |
NDG4082636
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.32 |
| Max. Negotiated Rate |
$424.15 |
| Rate for Payer: Adventist Health Commercial |
$99.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$266.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$342.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$424.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$274.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$374.25
|
| Rate for Payer: Blue Shield of California Commercial |
$309.88
|
| Rate for Payer: Blue Shield of California EPN |
$292.91
|
| Rate for Payer: Cash Price |
$224.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$324.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$424.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$424.15
|
| Rate for Payer: Dignity Health Senior |
$424.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$319.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$308.88
|
| Rate for Payer: Heritage Provider Network Senior |
$308.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$240.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$124.75
|
| Rate for Payer: Multiplan Commercial |
$374.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$424.15
|
| Rate for Payer: Vantage Medical Group Senior |
$424.15
|
|
