|
APPENDIX PROCEDURES WITH CC
|
Facility
|
IP
|
$23,943.64
|
|
|
Service Code
|
MSDRG 398
|
| Min. Negotiated Rate |
$17,868.39 |
| Max. Negotiated Rate |
$23,943.64 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,868.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,868.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,548.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,943.64
|
|
|
APPENDIX PROCEDURES WITH MCC
|
Facility
|
IP
|
$37,476.40
|
|
|
Service Code
|
MSDRG 397
|
| Min. Negotiated Rate |
$27,967.46 |
| Max. Negotiated Rate |
$37,476.40 |
| Rate for Payer: EPIC Health Plan Medicare |
$27,967.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27,967.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$32,162.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$37,476.40
|
|
|
APPENDIX PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,279.01
|
|
|
Service Code
|
MSDRG 399
|
| Min. Negotiated Rate |
$13,641.05 |
| Max. Negotiated Rate |
$18,279.01 |
| Rate for Payer: EPIC Health Plan Medicare |
$13,641.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,641.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,687.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,279.01
|
|
|
APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)
|
Facility
|
OP
|
$31,374.11
|
|
|
Service Code
|
CPT 20692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$31,374.11 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24,769.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18,163.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16,512.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24,769.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,163.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16,512.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$16,512.69
|
| Rate for Payer: Heritage Provider Network Senior |
$20,310.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,512.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$31,374.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,989.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,127.00
|
| Rate for Payer: Multiplan WC |
$26,048.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,163.96
|
| Rate for Payer: TriValley Medical Group Senior |
$18,163.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24,769.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,163.96
|
| Rate for Payer: Vantage Medical Group Senior |
$16,512.69
|
|
|
APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM
|
Facility
|
OP
|
$17,732.13
|
|
|
Service Code
|
CPT 20690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,158.00 |
| Max. Negotiated Rate |
$17,732.13 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9,332.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10,265.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9,332.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$9,332.70
|
| Rate for Payer: Heritage Provider Network Senior |
$11,479.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,332.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17,732.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,732.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,505.82
|
| Rate for Payer: Multiplan WC |
$14,462.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,265.97
|
| Rate for Payer: TriValley Medical Group Senior |
$10,265.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,999.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10,265.97
|
| Rate for Payer: Vantage Medical Group Senior |
$9,332.70
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$8,962.13
|
|
|
Service Code
|
CPT C5275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$8,962.13
|
|
|
Service Code
|
CPT C5271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$8,962.13 |
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Multiplan WC |
$1,239.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,093.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$918.00
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$950.57 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$950.57
|
| Rate for Payer: Heritage Provider Network Senior |
$1,169.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,806.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,093.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,045.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1,045.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$950.57 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$950.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,045.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$950.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$950.57
|
| Rate for Payer: Heritage Provider Network Senior |
$1,169.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$950.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,806.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,093.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,273.76
|
| Rate for Payer: Multiplan WC |
$3,703.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,045.63
|
| Rate for Payer: TriValley Medical Group Senior |
$1,045.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,544.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,984.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,425.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,045.63
|
| Rate for Payer: Vantage Medical Group Senior |
$950.57
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
OP
|
$15.42
|
|
|
Service Code
|
NDC 6131466505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$13.11 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.71
|
| Rate for Payer: Blue Shield of California Commercial |
$9.41
|
| Rate for Payer: Blue Shield of California EPN |
$7.52
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.54
|
| Rate for Payer: Heritage Provider Network Senior |
$9.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.79
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.17
|
| Rate for Payer: TriValley Medical Group Senior |
$6.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
|
IP
|
$15.42
|
|
|
Service Code
|
NDC 6131466505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$11.56 |
| Rate for Payer: Adventist Health Commercial |
$3.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.93
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.44
|
| Rate for Payer: Heritage Provider Network Senior |
$10.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
|
|
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]
|
Facility
|
OP
|
$31.53
|
|
|
Service Code
|
HCPCS J0185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$23.65 |
| Rate for Payer: Adventist Health Commercial |
$6.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.97
|
| Rate for Payer: Blue Shield of California Commercial |
$3.43
|
| Rate for Payer: Blue Shield of California EPN |
$3.43
|
| Rate for Payer: Cash Price |
$14.19
|
| Rate for Payer: Cash Price |
$14.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.18
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.60
|
| Rate for Payer: Heritage Provider Network Senior |
$14.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$15.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.13
|
| Rate for Payer: Multiplan Commercial |
$23.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.61
|
| Rate for Payer: TriValley Medical Group Senior |
$12.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Vantage Medical Group Senior |
$1.75
|
|
|
APREPITANT 130 MG/18 ML (7.2 MG/ML) INTRAVENOUS EMULSION [220348]
|
Facility
|
IP
|
$31.53
|
|
|
Service Code
|
HCPCS J0185
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$23.65 |
| Rate for Payer: Adventist Health Commercial |
$6.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.31
|
| Rate for Payer: Cash Price |
$14.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.60
|
| Rate for Payer: Heritage Provider Network Senior |
$14.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.88
|
| Rate for Payer: Multiplan Commercial |
$23.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.44
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$11.82
|
|
|
Service Code
|
NDC 6340291101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.91
|
| Rate for Payer: Blue Shield of California Commercial |
$7.21
|
| Rate for Payer: Blue Shield of California EPN |
$5.77
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.32
|
| Rate for Payer: Heritage Provider Network Senior |
$7.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$5.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$8.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.73
|
| Rate for Payer: TriValley Medical Group Senior |
$4.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.05
|
| Rate for Payer: Vantage Medical Group Senior |
$10.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 7074817501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 7074817501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 7074817530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 4359877730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 4359877711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 7074817530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 4359877711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 7226625930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 7226625930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION [77581]
|
Facility
|
IP
|
$11.82
|
|
|
Service Code
|
NDC 6340291101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$8.87 |
| Rate for Payer: Adventist Health Commercial |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.61
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.00
|
| Rate for Payer: Heritage Provider Network Senior |
$8.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.96
|
| Rate for Payer: Multiplan Commercial |
$8.87
|
|
