|
ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION [24585]
|
Facility
OP
|
$1,224.89
|
|
|
Service Code
|
CPT J7511
|
| Hospital Charge Code |
1759922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.71 |
| Max. Negotiated Rate |
$2,282.28 |
| Rate for Payer: Adventist Health Commercial |
$244.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,282.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$841.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,161.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,021.93
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,021.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$524.42
|
| Rate for Payer: Blue Shield of California Commercial |
$991.58
|
| Rate for Payer: Blue Shield of California EPN |
$991.58
|
| Rate for Payer: Cash Price |
$551.20
|
| Rate for Payer: Cash Price |
$551.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$563.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,393.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,021.93
|
| Rate for Payer: Dignity Health Senior |
$1,021.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$783.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$929.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$567.12
|
| Rate for Payer: Heritage Provider Network Senior |
$567.12
|
| Rate for Payer: Humana Medicare |
$929.03
|
| Rate for Payer: IEHP Medicare Advantage |
$929.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,765.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$221.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,096.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,170.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,170.57
|
| Rate for Payer: Multiplan Commercial |
$918.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,021.93
|
| Rate for Payer: TriValley Medical Group Senior |
$929.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$446.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$409.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,393.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,021.93
|
| Rate for Payer: Vantage Medical Group Senior |
$929.03
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]
|
Facility
OP
|
$1,584.00
|
|
|
Service Code
|
CPT J0841
|
| Hospital Charge Code |
ERX222871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.70 |
| Max. Negotiated Rate |
$2,607.29 |
| Rate for Payer: Adventist Health Commercial |
$316.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,240.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,088.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,140.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1,003.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,003.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2,607.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1,244.40
|
| Rate for Payer: Blue Shield of California EPN |
$1,244.40
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$728.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,368.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,003.28
|
| Rate for Payer: Dignity Health Senior |
$1,003.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,013.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$912.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$733.39
|
| Rate for Payer: Heritage Provider Network Senior |
$733.39
|
| Rate for Payer: Humana Medicare |
$912.08
|
| Rate for Payer: IEHP Medi-Cal |
$1,429.80
|
| Rate for Payer: IEHP Medicare Advantage |
$912.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,732.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$286.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,076.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$396.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,149.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,149.22
|
| Rate for Payer: Multiplan Commercial |
$1,188.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,003.28
|
| Rate for Payer: TriValley Medical Group Senior |
$912.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$577.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$529.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,368.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,003.28
|
| Rate for Payer: Vantage Medical Group Senior |
$912.08
|
|
|
ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION [222871]
|
Facility
IP
|
$1,584.00
|
|
|
Service Code
|
CPT J0841
|
| Hospital Charge Code |
ERX222871
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.70 |
| Max. Negotiated Rate |
$1,188.00 |
| Rate for Payer: Adventist Health Commercial |
$316.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,088.21
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$728.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$855.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,072.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1,072.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$286.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$396.00
|
| Rate for Payer: Multiplan Commercial |
$1,188.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$577.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$529.21
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
ERX199666
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.42
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: Dignity Health Senior |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.95
|
| Rate for Payer: Heritage Provider Network Senior |
$6.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 2.5 MG TABLET [199666]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0893-21
|
| Hospital Charge Code |
ERX199666
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.60
|
| Rate for Payer: Heritage Provider Network Senior |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.42
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: Dignity Health Senior |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.95
|
| Rate for Payer: Heritage Provider Network Senior |
$6.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-21
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.60
|
| Rate for Payer: Heritage Provider Network Senior |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
OP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.42
|
| Rate for Payer: Blue Shield of California Commercial |
$6.97
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.54
|
| Rate for Payer: Dignity Health Senior |
$9.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.95
|
| Rate for Payer: Heritage Provider Network Senior |
$6.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.54
|
| Rate for Payer: Vantage Medical Group Senior |
$9.54
|
|
|
APIXABAN 5 MG TABLET [199782]
|
Facility
IP
|
$11.22
|
|
|
Service Code
|
NDC 0003-0894-31
|
| Hospital Charge Code |
ERX199782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.71
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.60
|
| Rate for Payer: Heritage Provider Network Senior |
$7.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$9,042.61
|
|
|
Service Code
|
APR-DRG 2331
|
| Min. Negotiated Rate |
$9,042.61 |
| Max. Negotiated Rate |
$9,042.61 |
| Rate for Payer: IEHP Medi-Cal |
$9,042.61
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$16,923.18
|
|
|
Service Code
|
APR-DRG 2333
|
| Min. Negotiated Rate |
$16,923.18 |
| Max. Negotiated Rate |
$16,923.18 |
| Rate for Payer: IEHP Medi-Cal |
$16,923.18
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$11,678.09
|
|
|
Service Code
|
APR-DRG 2332
|
| Min. Negotiated Rate |
$11,678.09 |
| Max. Negotiated Rate |
$11,678.09 |
| Rate for Payer: IEHP Medi-Cal |
$11,678.09
|
|
|
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$25,316.13
|
|
|
Service Code
|
APR-DRG 2334
|
| Min. Negotiated Rate |
$25,316.13 |
| Max. Negotiated Rate |
$25,316.13 |
| Rate for Payer: IEHP Medi-Cal |
$25,316.13
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$13,925.56
|
|
|
Service Code
|
APR-DRG 2343
|
| Min. Negotiated Rate |
$13,925.56 |
| Max. Negotiated Rate |
$13,925.56 |
| Rate for Payer: IEHP Medi-Cal |
$13,925.56
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$7,333.38
|
|
|
Service Code
|
APR-DRG 2341
|
| Min. Negotiated Rate |
$7,333.38 |
| Max. Negotiated Rate |
$7,333.38 |
| Rate for Payer: IEHP Medi-Cal |
$7,333.38
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$23,715.33
|
|
|
Service Code
|
APR-DRG 2344
|
| Min. Negotiated Rate |
$23,715.33 |
| Max. Negotiated Rate |
$23,715.33 |
| Rate for Payer: IEHP Medi-Cal |
$23,715.33
|
|
|
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$9,471.41
|
|
|
Service Code
|
APR-DRG 2342
|
| Min. Negotiated Rate |
$9,471.41 |
| Max. Negotiated Rate |
$9,471.41 |
| Rate for Payer: IEHP Medi-Cal |
$9,471.41
|
|
|
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
|
Facility
OP
|
$31,243.54
|
|
|
Service Code
|
CPT 20692
|
| Min. Negotiated Rate |
$414.68 |
| Max. Negotiated Rate |
$31,243.54 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16,443.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,088.37
|
| Rate for Payer: Dignity Health Senior |
$16,443.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$16,443.97
|
| Rate for Payer: Humana Medicare |
$16,443.97
|
| Rate for Payer: IEHP Medi-Cal |
$414.68
|
| Rate for Payer: IEHP Medicare Advantage |
$16,443.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31,243.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19,403.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,719.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20,719.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,088.37
|
| Rate for Payer: TriValley Medical Group Senior |
$16,443.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16,443.97
|
|
|
Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
|
Facility
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 20690
|
| Min. Negotiated Rate |
$263.09 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,832.38
|
| Rate for Payer: Dignity Health Senior |
$8,938.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,938.53
|
| Rate for Payer: Humana Medicare |
$8,938.53
|
| Rate for Payer: IEHP Medi-Cal |
$263.09
|
| Rate for Payer: IEHP Medicare Advantage |
$8,938.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16,983.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10,547.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11,262.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11,262.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,832.38
|
| Rate for Payer: TriValley Medical Group Senior |
$8,938.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8,938.53
|
|
|
Application of interdental fixation device for conditions other than fracture or dislocation, includes removal
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21110
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: Dignity Health Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$1,905.44
|
| Rate for Payer: Humana Medicare |
$1,905.44
|
| Rate for Payer: IEHP Medi-Cal |
$103.38
|
| Rate for Payer: IEHP Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,620.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,248.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,400.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,095.98
|
| Rate for Payer: TriValley Medical Group Senior |
$1,905.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
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
|
| Min. Negotiated Rate |
$31.76 |
| 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 |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$31.76
|
|
|
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
|
| Min. Negotiated Rate |
$129.62 |
| 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 |
$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: IEHP Medi-Cal |
$129.62
|
| 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
|
|
|
Application of skin substitute graft to trunk, arms, legs, 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 15272
|
| Min. Negotiated Rate |
$22.32 |
| 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 |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$22.32
|
|
|
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
|
| Min. Negotiated Rate |
$112.63 |
| 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 |
$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: IEHP Medi-Cal |
$112.63
|
| 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
|
|
|
APRACLONIDINE 0.5 % EYE DROPS [9119]
|
Facility
OP
|
$15.42
|
|
|
Service Code
|
NDC 61314-665-05
|
| Hospital Charge Code |
1740300
|
|
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 Gatekeeper |
$8.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$13.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.56
|
| Rate for Payer: Blue Shield of California Commercial |
$9.58
|
| Rate for Payer: Blue Shield of California EPN |
$9.05
|
| 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 Senior |
$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 Permanente of CA Commercial |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.86
|
| Rate for Payer: Multiplan Commercial |
$11.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Vantage Medical Group Senior |
$13.11
|
|
