|
Arthroscopy, shoulder, surgical; repair of SLAP lesion
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 29807
|
| Min. Negotiated Rate |
$256.71 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$256.71
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 29825
|
| Min. Negotiated Rate |
$646.99 |
| 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 |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$646.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Arthroscopy, shoulder, surgical; with rotator cuff repair
|
Facility
|
OP
|
$16,983.21
|
|
|
Service Code
|
CPT 29827
|
| Min. Negotiated Rate |
$770.58 |
| Max. Negotiated Rate |
$16,983.21 |
| Rate for Payer: Aetna of CA Gatekeeper |
$5,088.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13,407.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,832.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,938.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9,792.00
|
| 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$770.58
|
| Rate for Payer: Inland Empire Health Plan (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
|
|
|
Arthroscopy, temporomandibular joint, surgical
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 29804
|
| Min. Negotiated Rate |
$719.02 |
| 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 |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$719.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 29846
|
| Min. Negotiated Rate |
$838.66 |
| 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 |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$838.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26070
|
| Min. Negotiated Rate |
$70.28 |
| 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 |
$3,012.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26080
|
| Min. Negotiated Rate |
$78.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,008.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,208.90
|
| Rate for Payer: Dignity Health Senior |
$2,008.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,008.09
|
| Rate for Payer: Humana Medicare |
$2,008.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$78.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,008.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3,815.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,369.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,530.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,530.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,208.90
|
| Rate for Payer: TriValley Medical Group Senior |
$2,008.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,012.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,208.90
|
| Rate for Payer: Vantage Medical Group Senior |
$2,008.09
|
|
|
Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 26075
|
| Min. Negotiated Rate |
$366.48 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,044.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,448.63
|
| Rate for Payer: Dignity Health Senior |
$4,044.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,044.21
|
| Rate for Payer: Humana Medicare |
$4,044.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$366.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,044.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,684.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,772.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,095.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,095.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,448.63
|
| Rate for Payer: TriValley Medical Group Senior |
$4,044.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,066.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,448.63
|
| Rate for Payer: Vantage Medical Group Senior |
$4,044.21
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 0998-0408-15
|
| Hospital Charge Code |
1740176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 0998-0408-15
|
| Hospital Charge Code |
1740176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
ARTIFICIAL TEARS EYE DROPS. [40820640]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Senior |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Senior |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.51
|
| Rate for Payer: Blue Shield of California Commercial |
$2.08
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.85
|
| Rate for Payer: Dignity Health Senior |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.34
|
| Rate for Payer: TriValley Medical Group Senior |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.85
|
| Rate for Payer: Vantage Medical Group Senior |
$2.85
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.27
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.30
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.27
|
| Rate for Payer: Heritage Provider Network Senior |
$2.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$2.51
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 1011902239
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 9999-9022-39
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.99
|
| Rate for Payer: Dignity Health Senior |
$1.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.94
|
| Rate for Payer: TriValley Medical Group Senior |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.99
|
| Rate for Payer: Vantage Medical Group Senior |
$1.99
|
|
|
ARTIFICIAL TEARS EYE OINTMENT [408111170]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 9999-9022-39
|
| Hospital Charge Code |
1740053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.61
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.76
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
IP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
1740326
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL [21058]
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 0065-8064-01
|
| Hospital Charge Code |
1740326
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.73
|
| Rate for Payer: Dignity Health Senior |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: Vantage Medical Group Senior |
$0.73
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS [27980]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 0998-0408-15
|
| Hospital Charge Code |
1740176
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
