|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
1743247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Senior |
$1.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 0168-0309-15
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-3
|
| Hospital Charge Code |
1743247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.61
|
| Rate for Payer: Heritage Provider Network Senior |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 0168-0309-15
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Senior |
$1.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESONIDE 0.05 % TOPICAL OINTMENT [9751]
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
NDC 51672-1281-1
|
| Hospital Charge Code |
1743237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Adventist Health Commercial |
$0.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.89
|
| Rate for Payer: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$2.26
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.27
|
| Rate for Payer: Dignity Health Senior |
$3.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Senior |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$2.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Senior |
$1.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.27
|
| Rate for Payer: Vantage Medical Group Senior |
$3.27
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
1743316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
OP
|
$3.29
|
|
|
Service Code
|
NDC 45802-495-35
|
| Hospital Charge Code |
1743316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: Dignity Health Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Senior |
$1.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
|
OP
|
$4,583.52
|
|
|
Service Code
|
CPT 64624
|
| Min. Negotiated Rate |
$585.00 |
| Max. Negotiated Rate |
$4,583.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,412.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,653.62
|
| Rate for Payer: Dignity Health Senior |
$2,412.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,412.38
|
| Rate for Payer: Humana Medicare |
$2,412.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$585.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,412.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,583.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,846.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,039.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,039.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,653.62
|
| Rate for Payer: TriValley Medical Group Senior |
$2,412.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2,412.38
|
|
|
Destruction by neurolytic agent; other peripheral nerve or branch
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64640
|
| Min. Negotiated Rate |
$195.73 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,138.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,252.71
|
| Rate for Payer: Dignity Health Senior |
$1,138.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,138.83
|
| Rate for Payer: Humana Medicare |
$1,138.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$195.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1,138.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,163.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,343.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,434.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,434.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,252.71
|
| Rate for Payer: TriValley Medical Group Senior |
$1,138.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,708.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,252.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1,138.83
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64634
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.96
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
|
Facility
|
OP
|
$4,583.52
|
|
|
Service Code
|
CPT 64633
|
| Min. Negotiated Rate |
$311.03 |
| Max. Negotiated Rate |
$4,583.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,412.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,653.62
|
| Rate for Payer: Dignity Health Senior |
$2,412.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,412.38
|
| Rate for Payer: Humana Medicare |
$2,412.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$311.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,412.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,583.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,846.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,039.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,039.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,653.62
|
| Rate for Payer: TriValley Medical Group Senior |
$2,412.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2,412.38
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 64636
|
| Min. Negotiated Rate |
$80.04 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.04
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
|
Facility
|
OP
|
$4,583.52
|
|
|
Service Code
|
CPT 64635
|
| Min. Negotiated Rate |
$304.73 |
| Max. Negotiated Rate |
$4,583.52 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,412.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,653.62
|
| Rate for Payer: Dignity Health Senior |
$2,412.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,412.38
|
| Rate for Payer: Humana Medicare |
$2,412.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$304.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,412.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,583.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,846.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,039.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,039.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,653.62
|
| Rate for Payer: TriValley Medical Group Senior |
$2,412.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,618.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,653.62
|
| Rate for Payer: Vantage Medical Group Senior |
$2,412.38
|
|
|
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 17110
|
| Min. Negotiated Rate |
$155.66 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$250.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$275.15
|
| Rate for Payer: Dignity Health Senior |
$250.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$250.14
|
| Rate for Payer: Humana Medicare |
$250.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$155.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$250.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$475.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$295.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$315.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$315.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$275.15
|
| Rate for Payer: TriValley Medical Group Senior |
$250.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$275.15
|
| Rate for Payer: Vantage Medical Group Senior |
$250.14
|
|
|
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 17106
|
| Min. Negotiated Rate |
$493.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: Dignity Health Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$498.20
|
| Rate for Payer: Humana Medicare |
$498.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$493.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$946.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$548.02
|
| Rate for Payer: TriValley Medical Group Senior |
$498.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 17108
|
| Min. Negotiated Rate |
$1,070.39 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,070.39
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 40820
|
| Min. Negotiated Rate |
$90.60 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$90.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Destruction of lesion, palate or uvula (thermal, cryo or chemical)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 42160
|
| Min. Negotiated Rate |
$117.90 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$117.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46910
|
| Min. Negotiated Rate |
$146.94 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$146.94
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46922
|
| Min. Negotiated Rate |
$148.68 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,508.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,858.96
|
| Rate for Payer: Dignity Health Senior |
$3,508.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,508.15
|
| Rate for Payer: Humana Medicare |
$3,508.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$148.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,508.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,665.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,139.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,420.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,420.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,858.96
|
| Rate for Payer: TriValley Medical Group Senior |
$3,508.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3,508.15
|
|
|
Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 56515
|
| Min. Negotiated Rate |
$191.29 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$191.29
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 56501
|
| Min. Negotiated Rate |
$281.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,417.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,506.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,278.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$281.46
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57061
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$91.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,421.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,296.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,906.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR [91073]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 0054-0400-13
|
| Hospital Charge Code |
ERX91073
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
